1
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Franklin O, Sugawara T, Ross RB, Rodriguez Franco S, Colborn K, Karam S, Schulick RD, Del Chiaro M. Adjuvant Chemotherapy With or Without Radiotherapy for Resected Pancreatic Cancer After Multiagent Neoadjuvant Chemotherapy. Ann Surg Oncol 2024; 31:4966-4975. [PMID: 38789615 DOI: 10.1245/s10434-024-15157-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 02/14/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Adjuvant therapy is associated with improved pancreatic cancer survival after neoadjuvant chemotherapy and surgery. However, whether adjuvant treatment should include radiotherapy is unclear in this setting. METHODS This study queried the National Cancer Database for pancreatic adenocarcinoma patients who underwent curative resection after multiagent neoadjuvant chemotherapy between 2010 and 2019 and received adjuvant treatment. Adjuvant chemotherapy plus radiotherapy (external beam, 45-50.4 gray) was compared with adjuvant chemotherapy alone. Uni- and multivariable Cox regression was used to assess survival associations. Analyses were repeated in a propensity score-matched subgroup. RESULTS Of 1983 patients who received adjuvant treatment after multiagent neoadjuvant chemotherapy and resection, 1502 (75.7%) received adjuvant chemotherapy alone and 481 (24.3%) received concomitant adjuvant radiotherapy (chemoradiotherapy). The patients treated with adjuvant chemoradiotherapy were younger, were treated at non-academic facilities more often, and had higher rates of lymph node metastasis (ypN1-2), positive resection margins (R1), and lymphovascular invasion (LVI+). The median survival was shorter for the chemoradiotherapy-treated patients according to the unadjusted analysis (26.8 vs 33.2 months; p = 0.0017). After adjustment for confounders, chemoradiotherapy was associated with better outcomes in the multivariable model (hazard ratio [HR], 0.75; 95% confidence interval [CI], 0.61-0.93; p = 0.008). The association between chemoradiotherapy and improved outcomes was stronger for the patients with grade III tumors (HR, 0.53; 95% CI, 0.37-0.74) or LVI+ tumors (HR, 0.58; 95% CI, 0.44-0.75). In a subgroup of 396 propensity-matched patients, chemoradiotherapy was associated with a survival benefit only for the patients with LVI+ or grade III tumors. CONCLUSION After multiagent neoadjuvant chemotherapy and resection for pancreatic cancer, additional adjuvant chemoradiotherapy versus adjuvant chemotherapy alone is associated with improved survival for patients with LVI+ or grade III tumors.
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Affiliation(s)
- Oskar Franklin
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Diagnostics and Intervention, Surgery, Umeå University, Umeå, Sweden
| | - Toshitaka Sugawara
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Richard Blake Ross
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Salvador Rodriguez Franco
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kathryn Colborn
- Department of Biostatistics and Informatics, University of Colorado School of Medicine, Aurora, CO, USA
- Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Sana Karam
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Richard D Schulick
- Department of Surgery, University of Colorado, Aurora, CO, USA
- University of Colorado Cancer Center, Aurora, CO, USA
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
- University of Colorado Cancer Center, Aurora, CO, USA.
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2
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Domagała-Haduch M, Gorzelak-Magiera A, Michalecki Ł, Gisterek-Grocholska I. Radiochemotherapy in Pancreatic Cancer. Curr Oncol 2024; 31:3291-3300. [PMID: 38920733 PMCID: PMC11202861 DOI: 10.3390/curroncol31060250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 05/23/2024] [Accepted: 06/03/2024] [Indexed: 06/27/2024] Open
Abstract
Despite the advancements made in oncology in recent years, the treatment of pancreatic cancer remains a challenge. Five-year survival rates for this cancer do not exceed 10%. Among the reasons contributing to poor treatment outcomes are the oligosymptomatic course of the tumor, diagnostic difficulties due to the anatomical location of the organ, and the unique biological features of pancreatic cancer. The mainstay of treatment for resectable cancer is surgery and adjuvant chemotherapy. For unresectable and metastatic cancers, chemotherapy remains the primary method of treatment. At the same time, for about thirty years, there have been attempts to improve treatment outcomes by using radiotherapy combined with systemic treatment. Unlike chemotherapy, radiotherapy has no established place in the treatment of pancreatic cancer. This paper addresses the topic of radiotherapy in pancreatic cancer as a valuable method that can improve treatment outcomes alongside chemotherapy.
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Affiliation(s)
- Małgorzata Domagała-Haduch
- Department of Oncology and Radiotherapy, Medical University of Silesia, 40-514 Katowice, Poland; (A.G.-M.); (Ł.M.); (I.G.-G.)
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3
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Del Chiaro M, Sugawara T, Karam SD, Messersmith WA. Advances in the management of pancreatic cancer. BMJ 2023; 383:e073995. [PMID: 38164628 DOI: 10.1136/bmj-2022-073995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
Pancreatic cancer remains among the malignancies with the worst outcomes. Survival has been improving, but at a slower rate than other cancers. Multimodal treatment, including chemotherapy, surgical resection, and radiotherapy, has been under investigation for many years. Because of the anatomical characteristics of the pancreas, more emphasis on treatment selection has been placed on local extension into major vessels. Recently, the development of more effective treatment regimens has opened up new treatment strategies, but urgent research questions have also become apparent. This review outlines the current management of pancreatic cancer, and the recent advances in its treatment. The review discusses future treatment pathways aimed at integrating novel findings of translational and clinical research.
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Affiliation(s)
- Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- University of Colorado Cancer Center, University of Colorado School of Medicine, Aurora, CO, USA
| | - Toshitaka Sugawara
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Sana D Karam
- University of Colorado Cancer Center, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Wells A Messersmith
- University of Colorado Cancer Center, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Medical Oncology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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4
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Ei S, Takahashi S, Ogasawara T, Mashiko T, Masuoka Y, Nakagohri T. Neoadjuvant and Adjuvant Treatments for Resectable and Borderline Resectable Pancreatic Ductal Adenocarcinoma: The Current Status of Pancreatic Ductal Adenocarcinoma Treatment in Japan. Gut Liver 2023; 17:698-710. [PMID: 36843421 PMCID: PMC10502496 DOI: 10.5009/gnl220311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 10/30/2022] [Accepted: 10/30/2022] [Indexed: 02/28/2023] Open
Abstract
Resection is the only curative treatment for pancreatic ductal adenocarcinoma (PDAC). Although the outcome of technically resectable PDAC has improved with advances in surgery and adjuvant therapy, the 5-year survival rate remains low at 20% to 40%. More effective therapy is needed. Almost 15 years ago, the National Comprehensive Cancer Network guidelines proposed a resectability classification of PDAC based on preoperative imaging. Since then, treatment strategies for PDAC have been devised based on resectability. The standard of care for resectable PDAC is adjuvant chemotherapy after R0 resection, as shown by the results of pivotal clinical trials. With regard to neoadjuvant treatment, several recent clinical trials comparing neoadjuvant treatment with upfront resection have been conducted on resectable PDAC and borderline resectable PDAC, and the benefits and efficacy of neoadjuvant treatment for pancreatic cancer has become clearer. The significance of neoadjuvant treatment for resectable PDAC remains controversial, but in borderline resectable PDAC the efficacy of neoadjuvant treatment has been further recognised, although the standard of care has not yet been established. Several promising clinical trials for PDAC are ongoing. This review presents previous and ongoing trials of perioperative treatment for resectable and borderline resectable PDAC, focusing on the difference between Asian and Western countries.
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Affiliation(s)
- Shigenori Ei
- Department of Gastroenterological Surgery, Tokai University School of Medicine, Isehara, Japan
| | - Shinichiro Takahashi
- Department of Gastroenterological Surgery, Tokai University School of Medicine, Isehara, Japan
| | - Toshihito Ogasawara
- Department of Gastroenterological Surgery, Tokai University School of Medicine, Isehara, Japan
| | - Taro Mashiko
- Department of Gastroenterological Surgery, Tokai University School of Medicine, Isehara, Japan
| | - Yoshihito Masuoka
- Department of Gastroenterological Surgery, Tokai University School of Medicine, Isehara, Japan
| | - Toshio Nakagohri
- Department of Gastroenterological Surgery, Tokai University School of Medicine, Isehara, Japan
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Al-Mansor E, Mahoney M, Chenard-Poirier M, Ramjeesingh R, Nair V, Kennedy E, Locke G, Welch S, Berry S, Couture F, Elimova E, Pollett A, Mahmud A, Wilson B, Armstrong D, Falkson C, Asmis T, Vickers M, Goodwin R. Eastern Canadian Gastrointestinal Cancer Consensus Conference 2023. Curr Oncol 2023; 30:8172-8185. [PMID: 37754508 PMCID: PMC10527697 DOI: 10.3390/curroncol30090593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 07/14/2023] [Accepted: 07/18/2023] [Indexed: 09/28/2023] Open
Abstract
The annual Eastern Canadian Gastrointestinal Cancer Consensus Conference 2023 was held in Quebec City, Quebec 2-4 February 2023. The purpose of the conference was to develop consensus statements on emerging and evolving treatment paradigms. Participants included Canadian medical oncologists, radiation oncologists, pathologists and surgical oncologists from across Ontario, Quebec, and the Atlantic provinces. Consensus statements were developed following rapid review presentations and discussion of available literature. The recommendations proposed here represent the consensus opinions of physicians involved in the care of patients with gastrointestinal malignancies who participated in this meeting.
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Affiliation(s)
- Essa Al-Mansor
- The Ottawa Hospital Cancer Centre, Ottawa, ON K1H 8L6, Canada (R.G.)
| | - Meghan Mahoney
- Faculty of Medicine, Memorial University of Newfoundland, Dr. H. Bliss Murphy Cancer Centre, St. John’s, NL A1B 3V6, Canadac
| | | | - Ravi Ramjeesingh
- Queen Elizabeth II Health Sciences Centre, Halifax, NS B3H 2Y9, Canada
| | - Vimoj Nair
- The Ottawa Hospital Cancer Centre, Ottawa, ON K1H 8L6, Canada (R.G.)
| | - Erin Kennedy
- Mount Sinai Hospital, Toronto, ON M5G 1X5, Canada; (E.K.)
| | - Gordon Locke
- The Ottawa Hospital Cancer Centre, Ottawa, ON K1H 8L6, Canada (R.G.)
| | - Stephen Welch
- London Regional Cancer Program, London, ON N6A 5W9, Canada;
| | - Scott Berry
- Department of Oncology, Cancer Centre of Southeastern Ontario, Queen’s University, Kingston, ON K7L 5P9, Canada; (S.B.)
| | - Felix Couture
- CHU de Québec—Université Laval, Québec, QC G1R 2J6, Canada (F.C.)
| | - Elena Elimova
- Princess Margaret Cancer Centre, Toronto, ON M5G 2C4, Canada
| | - Aaron Pollett
- Mount Sinai Hospital, Toronto, ON M5G 1X5, Canada; (E.K.)
| | - Aamer Mahmud
- Department of Oncology, Cancer Centre of Southeastern Ontario, Queen’s University, Kingston, ON K7L 5P9, Canada; (S.B.)
| | - Brooke Wilson
- Department of Oncology, Cancer Centre of Southeastern Ontario, Queen’s University, Kingston, ON K7L 5P9, Canada; (S.B.)
| | - Dawn Armstrong
- Faculty of Medicine, Memorial University of Newfoundland, Dr. H. Bliss Murphy Cancer Centre, St. John’s, NL A1B 3V6, Canadac
| | - Conrad Falkson
- Department of Oncology, Cancer Centre of Southeastern Ontario, Queen’s University, Kingston, ON K7L 5P9, Canada; (S.B.)
| | - Timothy Asmis
- The Ottawa Hospital Cancer Centre, Ottawa, ON K1H 8L6, Canada (R.G.)
| | - Michael Vickers
- The Ottawa Hospital Cancer Centre, Ottawa, ON K1H 8L6, Canada (R.G.)
| | - Rachel Goodwin
- The Ottawa Hospital Cancer Centre, Ottawa, ON K1H 8L6, Canada (R.G.)
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6
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Gottumukkala S, Salamekh S, Sanford NN. Current State and Future Directions of Radiation Therapy for Pancreas Adenocarcinoma. Surg Oncol Clin N Am 2023; 32:399-414. [PMID: 37182984 DOI: 10.1016/j.soc.2023.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
Studies suggest select patients from across the pancreatic adenocarcinoma (PDAC) disease spectrum may benefit from adding radiation therapy (RT) to multi-modality care. In resectable PDAC, there is an evolving role for neoadjuvant RT with adjuvant RT reserved for patients with increased recurrence risk. In borderline resectable PDAC, neoadjuvant chemoradiation likely improves R0 resection rates and in unresectable PDAC, definitive RT may prolong survival for some patients. Recent developments in RT delivery are promising but additional studies are needed to determine the benefit of these technologies and to optimize the role of RT in multi-modality care.
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7
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Yanagi T, Takama N, Kato E, Baba F, Kitase M, Shimohira M, Sawai H, Kato T, Matsuo Y, Shibamoto Y. Clinical Outcomes of Intraoperative Radiotherapy, Postoperative Radiotherapy, and Definitive Radiotherapy for Non-metastatic Pancreatic Cancer. Kurume Med J 2023; 67:163-170. [PMID: 36450483 DOI: 10.2739/kurumemedj.ms674002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
OBJECTIVE The aim of this study is to evaluate the utility of adjuvant radiotherapy (intraoperative radiotherapy, IORT; postoperative radiotherapy, PORT), and definitive radiotherapy for non-metastatic pancreatic cancer. METHODS Ninety-nine patients were analyzed. Thirty patients underwent IORT with surgery, 31 underwent PORT after surgery, and 38 underwent definitive radiotherapy. Tumor stage [Union for International Cancer Control (UICC) 2009] was as follows: Stage I, 7; IIA, 16; IIB, 31; III, 45. The doses for IORT, PORT, and definitive radio therapy were 20 to 30, 40 to 64.6, and 50.4 to 61.2 Gy, respectively. Associations between clinical parameters including age, gender, tumor site, stage, performance status, surgical margin, and use of chemotherapy and local control (LC) or overall survival (OS) were analyzed. RESULTS Follow-up periods for all patients were 1.1-145 months (median, 11). OS rate in the IORT, PORT, and definitive radiotherapy groups was 22%, 16%, and 6%, respectively, at 2 years. The 5-year OS rate was 13%, 3.2%, and 0%, respectively. Local control rate at 2 years was 33%, 35%, and 0%, respectively. No Grade ≥ 3 tox icities were observed. Distant metastasis was less common in the IORT group. Stage and surgical margin were sig nificant factors for OS after IORT. Performance status and chemotherapy were significant factors for OS after PORT and definitive radiotherapy. CONCLUSIONS The present study showed the safety of the three treatment modalities, but the outcomes were not satisfactory. More intensive strategies including radiotherapy should be investigated.
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Affiliation(s)
| | | | - Eriko Kato
- Department of Radiation Oncology, Nagoya Medical Center
| | - Fumiya Baba
- Department of Radiation Oncology, Nagoya West Medical Center
| | | | - Masashi Shimohira
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences
| | | | - Tomokatsu Kato
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences
| | - Yoichi Matsuo
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences
| | - Yuta Shibamoto
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences
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8
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Lu J, Tan J, Yu X. A prognostic model based on tumor microenvironment-related lncRNAs predicts therapy response in pancreatic cancer. Funct Integr Genomics 2023; 23:32. [PMID: 36625842 DOI: 10.1007/s10142-023-00964-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 12/21/2022] [Accepted: 01/02/2023] [Indexed: 01/11/2023]
Abstract
Pancreatic cancer is an aggressive malignant tumor with high mortality and a low survival rate. The immune and stromal cells that infiltrate in the tumor microenvironment (TME) significantly impact immunotherapy and drug responses. Therefore, we identify the TME-related lncRNAs to develop a prognostic model for predicting the therapy efficacy in pancreatic cancer patients. Firstly, we identified differentially expressed genes (DEGs) for weighted gene co-expression network analysis (WGCNA) to identify the TME-related module eigengenes. According to the module eigengenes, the TME-related prognostic lncRNAs were screened through the univariate Cox, least absolute shrinkage and selection operator (LASSO), and multivariate Cox analyses to construct a prognostic risk score (RS) model. Next, the predictive power of this model was evaluated by the time-dependent receiver operating characteristic (ROC) curve and Kaplan-Meier analyses. In addition, functional enrichment, immune cell infiltration, and somatic mutation analyses were performed. Finally, tumor immune dysfunction and exclusion (TIDE) score and drug sensitivity analyses were applied to predict therapy response. In this study, 11 TME-related prognostic lncRNAs were identified to develop the prognostic RS model. According to the RS, the low-risk patients had a better prognosis, lower rates of somatic mutation, lower TIDE scores, and higher sensitivity to gemcitabine and paclitaxel compared to high-risk patients. The findings above suggested that low-risk patients may benefit more from immunotherapy, and high-risk patients may benefit more from chemotherapy. Within this study, we established a prognostic RS model based on 11 TME-related lncRNAs, which may help improve clinical decision-making.
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Affiliation(s)
- Jianzhong Lu
- School of Sciences, Shanghai Institute of Technology, Shanghai, 201418, China
| | - Jinhua Tan
- School of Sciences, Shanghai Institute of Technology, Shanghai, 201418, China
| | - Xiaoqing Yu
- School of Sciences, Shanghai Institute of Technology, Shanghai, 201418, China.
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9
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de Jesus VHF, Riechelmann RP. Current Treatment of Potentially Resectable Pancreatic Ductal Adenocarcinoma: A Medical Oncologist's Perspective. Cancer Control 2023; 30:10732748231173212. [PMID: 37115533 PMCID: PMC10155028 DOI: 10.1177/10732748231173212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023] Open
Abstract
Pancreatic cancer has traditionally been associated with a dismal prognosis, even in early stages of the disease. In recent years, the introduction of newer generation chemotherapy regimens in the adjuvant setting has improved the survival of patients treated with upfront resection. However, there are multiple theoretical advantages to deliver early systemic therapy in patients with localized pancreatic cancer. So far, the evidence supports the use of neoadjuvant therapy for patients with borderline resectable pancreatic cancer. The benefit of this treatment sequence for patients with resectable disease remains elusive. In this review, we summarize the data on adjuvant therapy for pancreatic cancer and describe which evidence backs the use of neoadjuvant therapy. Additionally, we address important issues faced in clinical practice when treating patients with localized pancreatic cancer.
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10
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Cui J, Jiao F, Li Q, Wang Z, Fu D, Liang J, Liang H, Xia T, Zhang T, Zhang Y, Dai G, Zhang Z, Wang J, Bai Y, Bai Y, Bi F, Chen D, Cao D, Chen J, Fang W, Gao Y, Guo J, Hao J, Hua H, Huang X, Liu W, Liu X, Li D, Li J, Li E, Li Z, Pan H, Shen L, Sun Y, Tao M, Wang C, Wang F, Xiong J, Zhang T, Zhang X, Zhan X, Zheng L, Ren G, Zhang T, Zhou J, Ma Q, Qin S, Hao C, Wang L. Chinese Society of Clinical Oncology (CSCO): Clinical guidelines for the diagnosis and treatment of pancreatic cancer. JOURNAL OF THE NATIONAL CANCER CENTER 2022; 2:205-215. [PMID: 39036552 PMCID: PMC11256594 DOI: 10.1016/j.jncc.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 07/30/2022] [Accepted: 08/18/2022] [Indexed: 11/25/2022] Open
Abstract
Pancreatic cancer is one of the leading causes of cancer-related mortality in both developed and developing countries. The incidence of pancreatic cancer in China accounts for about a quater of the global incidence, and the epidemiological characteristics and therapeutic strategies differ due to social, economic, cultural, environmental, and public health factors. Non-domestic guidelines do not reflect the clinicopathologic characteristics and treatment patterns of Chinese patients. Thus, in 2018, the Chinese Society of Clinical Oncology (CSCO) organized a panel of senior experts from all sub-specialties within the field of pancreatic oncology to compile the Chinese guidelines for the diagnosis and treatment of pancreatic cancer. The guidelines were made based on both the Western and Eastern clinical evidence and updated every one or two years. The experts made consensus judgments and classified evidence-based recommendations into various grades according to the regional differences, the accessibility of diagnostic and treatment resources, and health economic indexes in China. Here we present the latest version of the guidelines, which covers the diagnosis, treatment, and follow-up of pancreatic cancer. The guidelines might standardize the diagnosis and treatment of pancreatic cancer in China and will encourage oncologists to design and conduct more clinical trials about pancreatic cancer.
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Affiliation(s)
- Jiujie Cui
- Department of Medical Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Feng Jiao
- Department of Medical Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qi Li
- Department of Medical Oncology, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zheng Wang
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Deliang Fu
- Department of Pancreatic Surgery, Huashan Hospital, Pancreatic Disease Institute, Fudan University, Shanghai, China
| | - Jun Liang
- Department of Oncology, Peking University International Hospital, Beijing, China
| | - Houjie Liang
- Department of Oncology and Southwest Cancer Center, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Tingyi Xia
- Beijing Huaxia Jingfang Cancer Radiotherapy Center, Former Air Force General Hospital and PLA General Hospital, Beijing, China
| | - Tao Zhang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yang Zhang
- Department of Oncology, The Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Guanghai Dai
- Department of Oncology, Chinese PLA General Hospital, Beijing, China
| | - Zhihong Zhang
- Department of Pathology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jian Wang
- Department of Imaging, Changzheng Hospital, Naval Military Medical University, Shanghai, China
| | - Yongrui Bai
- Department of Radiation Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yuxian Bai
- Oncology Department of Internal Medicine, Harbin Medical University Cancer Hospital, Harbin, China
| | - Feng Bi
- Department of Medical Oncology, West China Hospital, Sichuan University, Chengdu, China
| | - Donghui Chen
- Department of Medical Oncology, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Dan Cao
- Department of Medical Oncology, West China Hospital, Sichuan University, Chengdu, China
| | - Jie Chen
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Weijia Fang
- Department of Medical Oncology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yong Gao
- Department of Oncology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jianwei Guo
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Jihui Hao
- Department of Pancreatic Cancer, National Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Haiqing Hua
- Department of Medical Oncology, Eastern Theater Command General Hospital, Qinhuai Medical District, Nanjing, China
| | - Xinyu Huang
- Department of General Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Wenchao Liu
- Department of Clinical Oncology, Xijing Hospital, Air Force Medical University, Xian, China
| | - Xiufeng Liu
- Department of Medical Oncology, Eastern Theater Command General Hospital, Qinhuai Medical District, Nanjing, China
| | - Da Li
- Department of Medical Oncology, Sir Run Run Shaw Hospital, Zhejiang University, School of Medicine, Hangzhou, China
| | - Ji Li
- Department of Pancreatic Surgery, Huashan Hospital, Pancreatic Disease Institute, Fudan University, Shanghai, China
| | - Enxiao Li
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Zhiwei Li
- Department of Gastrointestinal Medical Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Hongming Pan
- Department of Medical Oncology, Sir Run Run Shaw Hospital, Zhejiang University, School of Medicine, Hangzhou, China
| | - Lin Shen
- Department of Gastrointestinal Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, China
| | - Yongwei Sun
- Department of Biliary-Pancreatic Surgery, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, China
| | - Min Tao
- Department of Oncology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Chengfeng Wang
- State Key Lab of Molecular Oncology & Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fenghua Wang
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Jianping Xiong
- Department of Oncology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Taiping Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xuebin Zhang
- Department of Interventional Oncology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Xianbao Zhan
- Department of Medical Oncology, Changhai Hospital of Shanghai, Navy Medical University, Shanghai, China
| | - Leizhen Zheng
- Department of Oncology, Xin Hua Hospital Affiliated To Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Gang Ren
- Peking University Shougang Hospital, Beijing, China
| | - Tingting Zhang
- Oncology Department of Internal Medicine, Harbin Medical University Cancer Hospital, Harbin, China
| | - Jun Zhou
- Department of Gastrointestinal Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, China
| | - Qingyong Ma
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Shukui Qin
- Department of Medical Oncology, Eastern Theater Command General Hospital, Qinhuai Medical District, Nanjing, China
| | - Chunyi Hao
- Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital, Beijing, China
| | - Liwei Wang
- Department of Medical Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Tang H, Qiao C, Lu J, Cheng Y, Dai M, Zhang T, Guo J, Wang Y, Bai C. Comparison of adjuvant gemcitabine plus S-1 with S-1 monotherapy for pancreatic ductal adenocarcinoma: Retrospective real-world data. Neoplasia 2022; 34:100841. [PMID: 36265240 PMCID: PMC9587333 DOI: 10.1016/j.neo.2022.100841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 10/04/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND S-1 has been recognized as one of the standard adjuvant chemotherapies for pancreatic ductal adenocarcinoma (PDAC) in East Asia, but the optimal adjuvant chemotherapy regimen has not been determined. We aimed to compare the efficacy and safety of adjuvant gemcitabine plus S-1 (GS) with S-1 monotherapy for PDAC. METHODS Patients with resected PDAC who received adjuvant GS or S-1 chemotherapy in Peking Union Medical College Hospital between May 2014 and May 2022 were reviewed. Data retrieved from medical records were used to evaluate efficacy and toxicity. RESULTS A total of 241 patients were included, with 167 receiving GS and 74 receiving S-1. The patients who received GS were generally younger (median [range] age: 62 [36-78] versus 64 [44-87] years, p = 0.004), but chemotherapy began later (median [range] interval between chemotherapy and surgery: 49 [17-125] versus 40 [16-100] days, p < 0.001). The median disease-free survival (DFS, 15.1 versus 15.9 months, p = 0.52) and overall survival (OS, 34.8 versus 27.1 months, p = 0.34) did not differ significantly between the GS and S-1 groups, even after adjustment for the biases. However, the chemotherapy completion rate was higher in the patients treated with S-1 (52.4% versus 75.7%, p = 0.006), while grade 3-4 neutropenia occurred more frequently in the GS group (49.5% versus 18.2%, p = 0.015). CONCLUSIONS Adjuvant S-1 monotherapy demonstrated noninferiority to the GS regimen in DFS and OS with better tolerability for PDAC following surgery.
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Affiliation(s)
- Hui Tang
- Department of Medical Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Caixia Qiao
- Department of Medical Oncology, Liaocheng Third People's Hospital, Liaocheng, China
| | - Jun Lu
- Department of General Surgery, Peking University Third Hospital, Peking University, Beijing, China
| | - Yuejuan Cheng
- Department of Medical Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Menghua Dai
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciencesand Peking Union Medical College, Beijing, China
| | - Taiping Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciencesand Peking Union Medical College, Beijing, China
| | - Junchao Guo
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciencesand Peking Union Medical College, Beijing, China
| | - Yingyi Wang
- Department of Medical Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chunmei Bai
- Department of Medical Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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12
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Seufferlein T, Mayerle J, Böck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie zum exokrinen Pankreaskarzinom – Langversion 2.0 – Dezember 2021 – AWMF-Registernummer: 032/010OL. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:e812-e909. [PMID: 36368658 DOI: 10.1055/a-1856-7346] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | | | - Stefan Böck
- Medizinische Klinik und Poliklinik III, Universitätsklinikum München, Germany
| | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsklinikum, Heidelberg, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Universitätsklinikum Hamburg-Eppendorf Medizinische Klinik und Poliklinik II Onkologie Hämatologie, Hamburg, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
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13
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Salamekh S, Gottumukkala S, Park C, Lin MH, Sanford NN. Radiotherapy for Pancreatic Adenocarcinoma: Recent Developments and Advances on the Horizon. Hematol Oncol Clin North Am 2022; 36:995-1009. [PMID: 36154787 DOI: 10.1016/j.hoc.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Current indications for radiotherapy in pancreatic cancer vary by surgical resectability status of the tumor. Radiation is generally not used pre-operatively for resectable tumors, but may be given adjuvantly particularly in settings of a close or positive surgical margin. For borderline resectable tumors, pre-operative radiation has been shown to improve surgical parameters including lowering nodal positivity and positive margin rates. For locally advanced unresectable tumors, radiation can improve local control, give patients an interval off of chemotherapy and provide symptomatic relief. Multidisciplinary discussion is critical for choosing the best modality and sequencing of care for patients with pancreatic cancer. Prospective trials with appropriately chosen endpoints and meticulous radiotherapy quality assurance are needed to best define populations with pancreatic cancer most likely to benefit from radiotherapy.
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Affiliation(s)
- Samer Salamekh
- Department of Radiation Oncology, University of Texas Southwestern, 2280 Inwood Road, Dallas, TX 75390, USA
| | - Sujana Gottumukkala
- Department of Radiation Oncology, University of Texas Southwestern, 2280 Inwood Road, Dallas, TX 75390, USA
| | - Chunjoo Park
- Department of Radiation Oncology, University of Texas Southwestern, 2280 Inwood Road, Dallas, TX 75390, USA
| | - Mu-Han Lin
- Department of Radiation Oncology, University of Texas Southwestern, 2280 Inwood Road, Dallas, TX 75390, USA
| | - Nina N Sanford
- Department of Radiation Oncology, University of Texas Southwestern, 2280 Inwood Road, Dallas, TX 75390, USA.
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14
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Seufferlein T, Mayerle J, Böck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie zum exokrinen Pankreaskarzinom – Kurzversion 2.0 – Dezember 2021, AWMF-Registernummer: 032/010OL. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:991-1037. [PMID: 35671996 DOI: 10.1055/a-1771-6811] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
| | | | - Stefan Böck
- Medizinische Klinik und Poliklinik III, Universitätsklinikum München, Germany
| | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsklinikum, Heidelberg, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Universitätsklinikum Hamburg-Eppendorf Medizinische Klinik und Poliklinik II Onkologie Hämatologie, Hamburg, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
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15
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Yamada Y. Present status and perspective of perioperative chemotherapy for patients with resectable pancreatic cancer in Japan. Glob Health Med 2022; 4:14-20. [PMID: 35291202 PMCID: PMC8884034 DOI: 10.35772/ghm.2021.01015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 09/07/2021] [Accepted: 10/01/2021] [Indexed: 06/14/2023]
Abstract
Adjuvant chemotherapy is the standard treatment for patients with resectable pancreatic ductal carcinoma. Perioperative chemotherapy has been given in less than 50% of patients with potentially resectable pancreatic cancer in Japan. A modified combination regimen of 5-fluorouracil, leucovorin, irinotecan, and oxaliplatin (mFOLFIRINOX; oxaliplatin 85 mg/m2, leucovorin 400 mg/m2, irinotecan 150 mg/m2 on day 1, and 5-fluorouracil 2,400 mg/m2 over 46 hours every 14 days for 12 cycles) is now preferred worldwide because it mitigates concerns regarding toxicity and tolerance. Adjuvant chemotherapeutic regimens employ S-1 in East Asia, whereas other areas use FOLFIRINOX, capecitabine plus gemcitabine, or gemcitabine monotherapy. Adjuvant chemoradiotherapy is not recommended because randomized controlled trials and meta-analyses revealed no survival benefit compared with chemotherapy. Preoperative chemotherapy with S-1 and gemcitabine combination chemotherapy for patients with resectable/borderline resectable pancreatic cancer significantly increased survival compared to upfront surgery in a recent clinical trial. Perioperative outcomes, including R0 resection rate and post-operative morbidity, were not significantly different between groups. When compared to upfront surgery, neoadjuvant S-1 and gemcitabine treatment significantly reduced the number of pathological nodal metastases in patients who underwent resection. Japanese guidelines therefore recommend neoadjuvant chemotherapy for patients with resectable pancreatic cancer. Preoperative chemotherapy can increase R0 cases by down-staging with higher relative dose intensity of chemotherapy. In contrast, patients who do not respond to chemotherapy may miss resection opportunities and would therefore be at a disadvantage. Therefore, it is critical for both patients and doctors that predictive markers for the response to chemotherapy are identified.
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Affiliation(s)
- Yasuhide Yamada
- Address correspondence to:Yasuhide Yamada, Comprehensive Cancer Center, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan. E-mail:
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16
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Akhter F, Manrique-Bedoya S, Moreau C, Smith AL, Feng Y, Mayer KM, Hood RL. Characterization of thermal and optical properties in porcine pancreas tissue. Lasers Surg Med 2022; 54:702-715. [PMID: 35170764 DOI: 10.1002/lsm.23523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 01/12/2022] [Accepted: 01/21/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Photothermal therapies have shown promise for treating pancreatic ductal adenocarcinoma when they can be applied selectively, but off-target heating can frustrate treatment outcomes. Improved strategies leveraging selective binding and localized heating are possible with precision medical approaches such as functionalized gold nanoparticles, but careful control of optical dosage and thermal generation would be imperative. However, the literature review revealed many groups assume liver properties for pancreas tissue or rely on insufficiently rigorous characterization studies. OBJECTIVE The objective of this study was to determine the thermal conductivity and optical properties at 808/1064 nm wavelengths in healthy samples of fresh and frozen porcine pancreas ex vivo. METHODS Thermal conductivity of the porcine pancreas tissue was measured by utilizing a hot plate and two K-type thermocouples. Experimental variables such as tissue sample thickness, hot plate temperature, and heat convection coefficient were estimated through the control experiments utilizing specimens with known thermal conductivity. Optical evaluations assessed light attenuation at the 808 and 1064 nm wavelengths (continuous wave, collimated beam) by measuring the light transmittance and reflectance of different tissue thicknesses. In turn, these measurements were input into an inverse adding-doubling program to estimate the optical absorption and reduced scattering coefficients. RESULTS Interestingly, pancreas tissue thermal conductivity was demonstrated to have no significant difference (p > 0.5) between samples that were fresh, frozen for 7 days, or frozen for 14 days. Conversely, optical property assessment exhibited a significant difference (p < 0.001) between fresh and frozen tissue samples, with increased absorbance and reflectance within the frozen group. However, the optical attenuation values measured were substantially less than that of the liver or reported in previous pancreas studies, suggesting a wide overestimation of these properties. CONCLUSIONS These thermal and optical properties are critical to the development of novel therapeutic strategies like plasmonic photothermal therapy, but perhaps more importantly, are invaluable towards informing better surgical planning and operative technique among the existing thermal approaches for treating pancreas tissue.
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Affiliation(s)
- Forhad Akhter
- Department of Mechanical Engineering, University of Texas at San Antonio (UTSA), San Antonio, Texas, USA
| | - Santiago Manrique-Bedoya
- Department of Mechanical Engineering, University of Texas at San Antonio (UTSA), San Antonio, Texas, USA
| | - Chris Moreau
- Gastroenterology and Transplant, UT Health San Antonio, San Antonio, Texas, USA
| | - Andrea Lynn Smith
- Department of Mechanical Engineering, University of Texas at San Antonio (UTSA), San Antonio, Texas, USA
| | - Yusheng Feng
- Department of Mechanical Engineering, University of Texas at San Antonio (UTSA), San Antonio, Texas, USA
| | - Kathryn M Mayer
- Department of Physics and Astronomy, University of Texas at San Antonio, San Antonio, Texas, USA
| | - R Lyle Hood
- Department of Mechanical Engineering, University of Texas at San Antonio (UTSA), San Antonio, Texas, USA.,Graduate School of Biomedical Sciences, UT Health San Antonio, San Antonio, Texas, USA
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17
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Altman AM, White MJ, Marmor S, Shukla D, Chang K, Lou E, LaRocca CJ, Hui JY, Tuttle TM, Jensen EH, Denbo JW. The Addition of Chemoradiation to Adjuvant Chemotherapy is Associated With Improved Survival Following Upfront Surgical Resection for Pancreatic Cancer With Nodal Metastases. Cancer Control 2022; 29:10732748221109991. [PMID: 35839251 PMCID: PMC9290159 DOI: 10.1177/10732748221109991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 05/18/2022] [Accepted: 05/31/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND It is unclear whether the addition of chemoradiation (CRT) to adjuvant chemotherapy (CT) following upfront resection of pancreatic ductal adenocarcinoma (PDAC) provides any benefit. While some studies have suggested a benefit to combined modality therapy (CMT) (adjuvant CT plus CRT), it is not clear if this benefit was related to increased CT usage in patients who received CMT. We sought to clarify the use of CMT in patients who underwent upfront resection of PDAC. METHODS Patients with non-metastatic PDAC were retrospectively identified from the linked SEER-Medicare database. Those who underwent upfront resection were identified and divided into two cohorts - patients who received adjuvant CT and patients who received adjuvant CMT. Cohorts were compared. Univariate analysis described patient characteristics. Kaplan-Meier and multivariable Cox proportional hazards modeling were used to estimate overall survival (OS). RESULTS 3555 patients were identified; 856 (24%) received CT and 573 (16%) received CMT. The median number of CT doses was 11 for both groups. Patients who received CMT were younger, diagnosed in the earlier time frame, and had fewer comorbidities. The median OS was 21 months and 18 months for those treated with CMT and CT (P < .0001), respectively, but when stratified by nodal status, the association with improved OS in the CMT cohort was only observed in node-positive patients. On multivariable analysis, receipt of CMT and removal of >15 lymph nodes decreased the risk of death (P < .05). DISCUSSION Receipt of CMT following upfront resection for PDAC was associated with improved survival, which was confined to node-positive patients. The role of adjuvant CMT in PDAC with nodal metastases warrants further study.
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Affiliation(s)
- Ariella M. Altman
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
- Division of Surgical Oncology, Department of Surgery, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - McKenzie J. White
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Schelomo Marmor
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
- Office of Academic Clinical Affairs, Masonic Cancer Center, University of Minnesota, Minneapolis, MN, USA
- Center for Clinical Quality & Outcomes Discovery & Evaluation (C-QODE), University of Minnesota, Minneapolis, MN, USA
| | - Dip Shukla
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
- Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Katherine Chang
- Division of Hematology, Department of Medicine, University of Minnesota Medical School, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Emil Lou
- Division of Hematology, Department of Medicine, University of Minnesota Medical School, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Christopher J. LaRocca
- Office of Academic Clinical Affairs, Masonic Cancer Center, University of Minnesota, Minneapolis, MN, USA
- Division of Surgical Oncology, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Jane Y.C. Hui
- Office of Academic Clinical Affairs, Masonic Cancer Center, University of Minnesota, Minneapolis, MN, USA
- Division of Surgical Oncology, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Todd M. Tuttle
- Office of Academic Clinical Affairs, Masonic Cancer Center, University of Minnesota, Minneapolis, MN, USA
- Division of Surgical Oncology, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Eric H. Jensen
- Office of Academic Clinical Affairs, Masonic Cancer Center, University of Minnesota, Minneapolis, MN, USA
- Division of Surgical Oncology, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Jason W. Denbo
- Office of Academic Clinical Affairs, Masonic Cancer Center, University of Minnesota, Minneapolis, MN, USA
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
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18
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Mehtsun WT, McCleary NJ, Maduekwe UN, Wolpin BM, Schrag D, Wang J. Patterns of Adjuvant Chemotherapy Use and Association With Survival in Adults 80 Years and Older With Pancreatic Adenocarcinoma. JAMA Oncol 2022; 8:88-95. [PMID: 34854874 PMCID: PMC8640950 DOI: 10.1001/jamaoncol.2021.5407] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
IMPORTANCE Patients 80 years and older with pancreatic ductal adenocarcinoma (PDAC) have not consistently received treatments that have established benefits in younger older adults (aged 60-79 years), yet patients 80 years and older are increasingly being offered surgery. Whether adjuvant chemotherapy (AC) provides additional benefit among patients 80 years and older with PDAC following surgery is not well understood. OBJECTIVE To describe patterns of AC use in patients 80 years and older following surgical resection of PDAC and to compare overall survival between patients who received AC and those who did not. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study among patients 80 years or older diagnosed with PDAC (stage I-III) between 2004 to 2016 who underwent a pancreaticoduodenectomy at hospitals across the US reporting to the National Cancer Database. EXPOSURES AC vs no AC 90 days following diagnosis of PDAC. MAIN OUTCOMES AND MEASURES The proportion of patients who received AC was assessed over the study period. Overall survival was compared between patients who received AC and those who did not using Kaplan-Meier estimates and multivariable Cox proportional hazards regression. A landmark analysis was performed to address immortal time bias. A propensity score analysis was performed to address indication bias. Subgroup analyses were conducted in node-negative, margin-negative, clinically complex, node-positive, and margin-positive cohorts. RESULTS Between 2004 and 2016, 2569 patients 80 years and older (median [IQR] age, 82 [81-84] years; 1427 were women [55.5%]) underwent surgery for PDAC. Of these patients, 1217 (47.4%) received AC. Findings showed an 18.6% (95% CI, 8.0%-29.0%; P = .001) absolute increase in the use of AC among older adults who underwent a pancreaticoduodenectomy comparing rates in 2004 vs 2016. Receipt of AC was associated with a longer median survival (17.2 months; 95% CI, 16.1-19.0) compared with those who did not receive AC (12.7 months; 95% CI, 11.8-13.6). This association was consistent in propensity and subgroup analyses. In multivariable analysis, receipt of AC (hazard ratio [HR], 0.72; 95% CI, 0.65-0.79; P < .001), female sex (HR, 0.88; 95% CI, 0.80-0.96; P < .001), and surgery in the more recent time period (≥2011) (HR, 0.90; 95% CI, 0.82-0.99; P = .02) were associated with a decreased hazard of death. An increased hazard of death was associated with higher pathologic stage (stage II: HR, 1.68; 95% CI, 1.43-1.97; P < .001; stage III: HR, 2.39; 95% CI, 1.88-3.04; P < .001), positive surgical margins (HR, 1.49; 95% CI, 1.34-1.65; P < .001), length of stay greater than median (10 days) (HR, 1.17; 95% CI, 1.07-1.28; P < .001), and receipt of oncologic care at a nonacademic facilities (Community Cancer Program: HR, 1.20; 95% CI, 1.07-1.35; P < .001; Integrated Network Cancer Program: HR, 1.25; 95% CI, 1.07-1.46; P < .001). CONCLUSIONS AND RELEVANCE In this cohort study, the use of AC among patients who underwent resection for PDAC increased over the study period, yet it still was administered to fewer than 50% of patients. Receipt of AC was associated with a longer median survival.
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Affiliation(s)
- Winta T. Mehtsun
- Division of Surgical Oncology, Department of Surgery, University of California San Diego
| | - Nadine J. McCleary
- Department of Medical Oncology, Gastrointestinal Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Ugwuji N. Maduekwe
- Division of Surgical Oncology, Department of Surgery, University of North Carolina at Chapel Hill
| | - Brian M. Wolpin
- Department of Medical Oncology, Gastrointestinal Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Deborah Schrag
- Department of Medical Oncology, Gastrointestinal Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jiping Wang
- Division of Surgical Oncology, Department of Surgery, Dana-Farber Cancer Institute, Mass General Brigham, Boston, Massachusetts
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19
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Huguet F, Rivin Del Campo E, Orthuon A, Mornex F, Bessières I, Guimas V, Vendrely V. Radiation therapy of pancreatic cancers. Cancer Radiother 2021; 26:259-265. [PMID: 34953706 DOI: 10.1016/j.canrad.2021.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We present the update of the recommendations of the French society of oncological radiotherapy on radiotherapy of pancreatic tumors. Currently, the use of radiation therapy for patients with pancreatic cancer is subject to discussion. In the adjuvant setting, the standard treatment is six months of chemotherapy with 5-fluorouracile, irinotecan and oxaliplatin. Chemoradiation may improve the survival of patients with incompletely resected tumours (R1). This remains to be confirmed by a prospective trial. Neoadjuvant chemoradiation is a promising treatment especially for patients with borderline resectable tumours. For patients with locally advanced tumours, there is no standard. An induction chemotherapy followed by chemoradiation for non progressive patients reduces the rate of local relapse. Whereas in the first trials of chemoradiation large fields were used, the treated volumes have been reduced to improve tolerance. Tumour movements induced by breathing should be taken in account. Intensity modulated radiation therapy allows a reduction of doses to the organs at risk. Whereas widely used, this technique has poor evidence-based recommendation. Stereotactic body radiation therapy is also being studied, as a neoadjuvant or exclusive treatment.
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Affiliation(s)
- F Huguet
- Service d'oncologie radiothérapie, hôpital Tenon, hôpitaux universitaires Est Parisien, Sorbonne Université, 4, rue de la Chine, 75020 Paris, France.
| | - E Rivin Del Campo
- Service d'oncologie radiothérapie, hôpital Tenon, hôpitaux universitaires Est Parisien, Sorbonne Université, 4, rue de la Chine, 75020 Paris, France
| | - A Orthuon
- Service d'oncologie radiothérapie, hôpital Tenon, hôpitaux universitaires Est Parisien, Sorbonne Université, 4, rue de la Chine, 75020 Paris, France
| | - F Mornex
- Service de radiothérapie, centre hospitalier Lyon-Sud, hospices civils, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite, France
| | - I Bessières
- Département de physique médicale, centre Georges-François-Leclerc, 1, rue Professeur-Marion, 21000 Dijon, France
| | - V Guimas
- Service d'oncologie radiothérapie, institut de cancérologie de l'Ouest centre René-Gauducheau, boulevard Jacques-Monod, 44800 Saint-Herblain, France
| | - V Vendrely
- Service de radiothérapie, CHU de Bordeaux, 33604 Pessac cedex, France
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20
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Xing J, Yang B, Hou X, Jia N, Gong X, Li X, Zhou N, Cheng Y, Bai C. Prognostic Factors and Effect of Adjuvant Chemoradiation Following Chemotherapy in Resected Pancreatic Cancer Patients With Lymph Node Metastasis or R1 Resection. Front Oncol 2021; 11:660215. [PMID: 34631515 PMCID: PMC8493064 DOI: 10.3389/fonc.2021.660215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 09/06/2021] [Indexed: 12/17/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is a lethal disease with a poor prognosis. In resectable PDAC, the recurrence rate is still high even when surgery and adjuvant chemotherapy (CT) are applied. Regional lymph node metastasis and positive margins are associated with higher recurrence risk and worse survival. Adjuvant radiotherapy has been explored, but its efficacy remains controversial. In recent years, some characteristics have been reported to stratify patients who may benefit from adjuvant chemoradiation (CRT), such as lymph node metastasis and margin status. Adjuvant chemotherapy followed by chemoradiation (CT-CRT) was also proposed. A total of 266 patients with resectable PDAC who have lymph node metastasis or R1 resection after surgery were enrolled. In multivariate Cox regression analyses, pancreatic body or tail tumor location (HR 0.433, p<0.0001, compared with pancreatic head) and adjuvant CT predicted a better survival, while there were no significant differences among the different CT regimens. Higher T stage indicated poor survival (stage I: reference; stage II: HR 2.178, p=0.014; stage III: HR 3.581, p=0.001). Propensity score matching was applied in 122 patients to explore the role of CRT. A cohort of 51 patients (31 and 20 patients in the CT and CT-CRT groups, respectively) was generated by matching. Further analyses revealed adjuvant CT-CRT was associated with prolonged survival compared with CT alone (HR 0.284, p=0.014) and less frequent local recurrences (56.5% vs. 21.4% in the CT and CT-CRT group, respectively). However, no significant differences in disease-free survival among these two groups were observed.
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Affiliation(s)
- Jiazhang Xing
- Department of Medical Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Bo Yang
- Department of Radiotherapy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaorong Hou
- Department of Radiotherapy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Ning Jia
- Department of Medical Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaolei Gong
- Department of Medical Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaoyuan Li
- Department of Medical Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Na Zhou
- Department of Medical Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yuejuan Cheng
- Department of Medical Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Chunmei Bai
- Department of Medical Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
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21
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Korean clinical practice guideline for pancreatic cancer 2021: A summary of evidence-based, multi-disciplinary diagnostic and therapeutic approaches. Pancreatology 2021; 21:1326-1341. [PMID: 34148794 DOI: 10.1016/j.pan.2021.05.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/20/2021] [Accepted: 05/04/2021] [Indexed: 02/08/2023]
Abstract
Pancreatic cancer is the eighth most common cancer and the fifth most common cause of cancer-related death in Korea. To enable standardization of management and facilitate improvements in outcome, a total of 53 multi-disciplinary experts in gastroenterology, surgery, medical oncology, radiation oncology, radiology, nuclear medicine, and pathology in Korea developed new recommendations that integrate the most up-to-date, evidence-based research findings and expert opinions. Recommendations were made on imaging diagnosis, endoscopic management, surgery, radiotherapy, palliative chemotherapy, and specific management procedures, including neoadjuvant treatment or adjuvant treatment for patients with resectable, borderline resectable, and locally advanced unresectable pancreatic cancer. This is the English version of the Korean clinical practice guideline for pancreatic cancer 2021. This guideline includes 20 clinical questions and 32 statements. This guideline represents the most standard guideline for the diagnosis and treatment of patients with pancreatic ductal adenocarcinoma in adults at this time in Korea. The authors believe that this guideline will provide useful and informative advice.
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Han D, Gao F, Liu JL, Wang H, Fu Q, Yang GW. Analysis of radiotherapy impact on survival in resected stage I/II pancreatic cancer patients: a population-based study. BMC Cancer 2021; 21:560. [PMID: 34001035 PMCID: PMC8130297 DOI: 10.1186/s12885-021-08288-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 05/04/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The application of radiotherapy (RT) in pancreatic cancer remains controversial. AIM The aim of the study was to evaluate the efficacy of radiotherapy (neoadjuvant and adjuvant radiotherapy) for resectable I/II pancreatic cancer. METHODS Fourteen thousand nine hundred seventy-seven patients with pancreatic cancer were identified from SEER database from 2004 to 2015. Multivariate analyses were performed to determine factors including RT on overall survival. Overall survival and overall mortality among the different groups were evaluated using the Kaplan-Meier method and Gray's test. RESULTS Patients were divided into groups according to whether they received radiotherapy or not. The median survival time of all 14,977 patients without RT was 20 months, neoadjuvant RT was 24 months and adjuvant RT was 23 months (p < 0.0001). Median survival time of 2089 stage I patients without RT was 56 months, significantly longer than those with RT regardless of neoadjuvant or adjuvant RT (no RT: 56 months vs adjuvant RT: 37 months vs neoadjuvant RT: 27 months, P = 0.0039). Median survival time of 12,888 stage II patients with neoadjuvant RT was 24 months, adjuvant RT 22 months, significantly prolonged than those without radiotherapy (neoadjuvant RT: 24 months vs adjuvant RT: 22 months vs no RT: 17 months, P<0.0001). Neoadjuvant RT (HR = 1.434, P = 0.023, 95% CI: 1.051-1.957) was independent risk factors for prognosis of stage I patients, and adjuvant RT (HR = 0.904, P < 0.001, 95% CI: 0.861-0.950) predicted better outcomes for prognosis of stage II patients by multivariate analysis. The risk of cancer-related death caused by neoadjuvant RT in stage I and no-RT in stage II patients were significantly higher. CONCLUSIONS The study identified a significant survival advantage for the use of adjuvant RT over surgery alone or neoadjuvant RT in treating stage II pancreatic cancer. RT was not associated with survival benifit in stage I patients.
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Affiliation(s)
- Dong Han
- Department of Oncology & Hematology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, No.23 Back street in the Museum of Art Rd, Dongcheng District, Beijing, China
| | - Fei Gao
- Department of Oncology & Hematology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, No.23 Back street in the Museum of Art Rd, Dongcheng District, Beijing, China
| | - Jin Long Liu
- Department of Oncology, LuanPing Hospital of Traditional Chinese Medicine, No.57, Baojian Road, Xinjian Street, Luanping Town, Chengde City, HeBei Province, China
| | - Hao Wang
- Department of Oncology & Hematology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, No.23 Back street in the Museum of Art Rd, Dongcheng District, Beijing, China
| | - Qi Fu
- Department of Oncology & Hematology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, No.23 Back street in the Museum of Art Rd, Dongcheng District, Beijing, China.
| | - Guo Wang Yang
- Department of Oncology & Hematology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, No.23 Back street in the Museum of Art Rd, Dongcheng District, Beijing, China.
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Nehlsen AD, Goodman KA. Controversies in radiotherapy for pancreas cancer. J Surg Oncol 2021; 123:1460-1466. [PMID: 33831248 DOI: 10.1002/jso.26313] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 11/14/2020] [Indexed: 12/31/2022]
Abstract
The management of pancreatic adenocarcinoma remains an area of controversy and ongoing discovery. Despite advances in surgical and radiation techniques, as well as chemotherapeutic agents, outcomes of patients diagnosed with this devastating malignancy remain poor. This article aims to review the available literature evaluating the efficacy of adjuvant, neoadjuvant, and definitive radiation therapy. We will also highlight areas of ongoing research efforts being carried out to improve outcomes in this patient population.
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Affiliation(s)
- Anthony D Nehlsen
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Karyn A Goodman
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, USA
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Establishing an immunocompromised porcine model of human cancer for novel therapy development with pancreatic adenocarcinoma and irreversible electroporation. Sci Rep 2021; 11:7584. [PMID: 33828203 PMCID: PMC8027815 DOI: 10.1038/s41598-021-87228-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 03/25/2021] [Indexed: 02/07/2023] Open
Abstract
New therapies to treat pancreatic cancer are direly needed. However, efficacious interventions lack a strong preclinical model that can recapitulate patients’ anatomy and physiology. Likewise, the availability of human primary malignant tissue for ex vivo studies is limited. These are significant limitations in the biomedical device field. We have developed RAG2/IL2RG deficient pigs using CRISPR/Cas9 as a large animal model with the novel application of cancer xenograft studies of human pancreatic adenocarcinoma. In this proof-of-concept study, these pigs were successfully generated using on-demand genetic modifications in embryos, circumventing the need for breeding and husbandry. Human Panc01 cells injected subcutaneously into the ears of RAG2/IL2RG deficient pigs demonstrated 100% engraftment with growth rates similar to those typically observed in mouse models. Histopathology revealed no immune cell infiltration and tumor morphology was highly consistent with the mouse models. The electrical properties and response to irreversible electroporation of the tumor tissue were found to be similar to excised human pancreatic cancer tumors. The ample tumor tissue produced enabled improved accuracy and modeling of the electrical properties of tumor tissue. Together, this suggests that this model will be useful and capable of bridging the gap of translating therapies from the bench to clinical application.
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Ghaly M, Gogineni E, Herman J, Saif MW. New Potential Options for SBRT in Pancreatic Cancer. CANCER MEDICINE JOURNAL 2021; 4:41-50. [PMID: 34355218 PMCID: PMC8336074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Stereotactic body radiotherapy (SBRT) is an emerging treatment option for patients with pancreatic cancer, as it can provide a therapeutic benefit with significant advantages for patients' quality of life over standard conventional chemoradiation (CRT). The objective of this review is to present alternative clinical settings in which SBRT may benefit patients with pancreatic cancer. These include palliation of pain, elderly patients who are not surgical candidates, local therapy in oligometastatic cases and salvaging local failures after surgery or external beam radiation. We will review these individually and provide supporting literature for each.
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Affiliation(s)
- Maged Ghaly
- Northwell Health Cancer Institute, Lake Success, NY 11042, USA
| | - Emile Gogineni
- Northwell Health Cancer Institute, Lake Success, NY 11042, USA
| | - Joseph Herman
- Northwell Health Cancer Institute, Lake Success, NY 11042, USA
| | - Muhammad W Saif
- Northwell Health Cancer Institute, Lake Success, NY 11042, USA
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Is Laparoscopic Pancreaticoduodenectomy Feasible for Pancreatic Ductal Adenocarcinoma? Cancers (Basel) 2020; 12:cancers12113430. [PMID: 33218187 PMCID: PMC7699219 DOI: 10.3390/cancers12113430] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/11/2020] [Accepted: 11/14/2020] [Indexed: 02/08/2023] Open
Abstract
Simple Summary Pancreatic cancer is known to be one of the most lethal malignant diseases in gastrointestinal tract. Margin-negative pancreatectomy followed by postoperative adjuvant chemotherapy is essential treatment for long-term survival. Due to anatomical complexity and technical difficulty, laparoscopic pancreaticoduodenectomy is still controversial. However, with the advance of laparoscopic surgery, laparoscopic pancreatic resection of pancreatic head cancer has been carefully applied in well selected patients. The accumulating data are suggesting its technical feasibility, safety, and potential equivalent long-term oncologic outcome. In this review, the current status of laparoscopic pancreaticoduodenectomy for pancreatic head cancer is summarized. In addition, potential surgical indications and future perspectives of laparoscopic pancreaticoduodenectomy for pancreatic cancer are discussed for safe implementation in our clinical practice. Abstract Margin-negative radical pancreatectomy is the essential condition to obtain long-term survival of patients with pancreatic cancer. With the investigation for early diagnosis, introduction of potent chemotherapeutic agents, application of neoadjuvnat chemotherapy, advancement of open and laparoscopic surgical techniques, mature perioperative management, and patients’ improved general conditions, survival of the resected pancreatic cancer is expected to be further improved. According to the literatures, laparoscopic pancreaticoduodenectomy (LPD) is also thought to be good alternative strategy in managing well-selected resectable pancreatic cancer. LPD with combined vascular resection is also feasible, but only expert surgeons should handle these challenging cases. LPD for pancreatic cancer should be determined based on surgeons’ proficiency to fulfil the goals of the patient’s safety and oncologic principles.
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Mangieri CW, Strode MA, Moaven O, Clark CJ, Shen P. Utilization of chemoradiation therapy provides strongest protective effect for avoidance of postoperative pancreatic fistula following pancreaticoduodenectomy: A NSQIP analysis. J Surg Oncol 2020; 122:1604-1611. [PMID: 32935353 DOI: 10.1002/jso.26202] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/05/2020] [Accepted: 08/20/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND The utilization of neoadjuvant therapy (NAT) before performing pancreaticoduodenectomy for malignancy has been well established as a protective factor for the prevention of postoperative pancreatic fistula (POPF). However, there is a paucity of published data evaluating the specific NAT regimen that is the most protective against POPF development. We evaluated the differences between neoadjuvant chemotherapy (CT) and chemoradiation therapy (CRT) with regard to the effect on POPF rates. METHODS The main and targeted pancreatectomy American College of Surgeons National Surgical Quality Improvement Program registries for 2014-2016 were retrospectively reviewed. A total of 10,665 pancreaticoduodenectomy cases were present. The primary outcome was POPF development. The factors that have previously been shown to be associated with or suspected to be associated with POPF were evaluated. The factors included NAT, sex, age, body mass index (BMI), diabetes, smoking, steroid therapy, preoperative weight loss, preoperative albumin level, perioperative blood transfusions, wound classification, American Society of Anesthesiologists classification, duct size (<3 mm, 3-6 mm, and >6 mm), gland texture (soft, intermediate, and hard), and anastomotic technique. The factors identified to be statistically significant were then used for propensity score matching to compare POPF development between the cases utilizing CT versus CRT. RESULTS A total of 10,117 cases met the inclusion criteria. The development of POPF was significantly associated, on multivariate analysis, with a lack of NAT, male sex, higher BMI, nondiabetic status, nonsmoker status, decreased weight loss, preoperative albumin level, decreased duct size, and soft gland texture. NAT, duct size, and gland texture had the strongest associations with the development of POPF (p < .0001). The overall 1765 cases (17.45%) received NAT and the POPF rate for cases with NAT was 10.20% versus 20.10% for cases without NAT (p < .0001). A total of 1031 cases underwent CT and 734 cases underwent CRT, respectively. A total of 708 paired cases were selected for analysis based on propensity score matching. The POPF rates were 11.20% versus 3.50% for CT and CRT, respectively (p < .0001). There was no difference in the frequencies of specific POPF grades. The decreased POPF rate with CRT correlated with firmer gland texture rates. CONCLUSIONS To our knowledge, this is the largest analysis of specific NAT regimens with regard to the development of POPF following pancreaticoduodenectomy. CRT provided the strongest protective effect. That protective effect is most likely due to increased fibrosis in the pancreatic parenchyma from radiation therapy. These findings provide additional support to consider CRT over CT alone in the treatment of pancreatic cancer when NAT will be utilized.
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Affiliation(s)
- Christopher W Mangieri
- Department of Surgical Oncology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, USA
- Department of General Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia, USA
| | - Matthew A Strode
- Department of Surgery, Womack Army Medical Center, Fort Bragg, North Carolina, USA
| | - Omeed Moaven
- Department of Surgical Oncology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Clancy J Clark
- Department of Surgical Oncology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Perry Shen
- Department of Surgical Oncology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, USA
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Patel AK, Rodríguez-López JL, Bahary N, Zureikat AH, Burton SA, Heron DE, Olson AC. Patterns of Failure After Adjuvant Stereotactic Body Radiation Therapy for Pancreatic Cancer With Close or Positive Margins. Adv Radiat Oncol 2020; 5:1197-1205. [PMID: 33305081 PMCID: PMC7718532 DOI: 10.1016/j.adro.2020.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 07/31/2020] [Accepted: 08/19/2020] [Indexed: 12/15/2022] Open
Abstract
Purpose There is no consensus on treatment volumes for adjuvant stereotactic body radiation therapy (SBRT) for pancreatic cancer. Herein, we report patterns of failure after pancreatic SBRT for close/positive margins, which may inform target volume design. Methods and Materials An institutional review board-approved retrospective review of patients with pancreatic adenocarcinoma treated with adjuvant SBRT for close/positive margins from 2009 to 2018 was conducted. Patterns of failure were defined as local (LF) within the tumor bed, regional (RF) within lymph nodes or anastomoses, or distant (DF). The cumulative incidence of locoregional failure was calculated using the cumulative incidence function accounting for the competing risk of death. LFs were mapped to the planning target volume (PTV) and classified as in-field (completely within the PTV), marginal (partially within the PTV), or out-of-field (completely outside the PTV). The location of LFs was compared with the Radiation Therapy Oncology Group 0848 contouring atlas to determine whether standard postoperative radiation therapy volumes would have included the LF. Results Seventy-six patients were treated with adjuvant SBRT for close (51.3%) or positive (48.7%) margins. Most (81.6%) received 36 Gy in 3 fractions, with a median PTV volume of 17.8 cc (interquartile range, 12.1-25.6). With a median follow-up of 17.0 months (interquartile range, 7.3-28.4), crude rates of first isolated LF, isolated RF, and DF +/- LF or RF were 9.2%, 6.6%, and 56.6%, respectively. Two-year cumulative incidences of LF, RF, locoregional failure, and DF were 34.9%, 30.8%, 49.2%, and 60.4%, respectively. Of 28 reviewable LFs, 21.4% were in-field while the remainder were completely outside (60.7%) or partially outside (17.9%) the PTV. Most LFs (92.9%) would have been encompassed by the Radiation Therapy Oncology Group consensus target volumes. Conclusions After adjuvant pancreatic SBRT for close/positive margins, the majority of LFs were outside the PTV but within contemporary target volumes for conventional radiation therapy.
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Affiliation(s)
- Ankur K Patel
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Joshua L Rodríguez-López
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Nathan Bahary
- Department of Medicine, Division of Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Amer H Zureikat
- Department of Surgery, Division of GI Surgical Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Steven A Burton
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Dwight E Heron
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Adam C Olson
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Kim BH, Kim K, Jang JY, Kwon W, Kim H, Lee KH, Oh DY, Kim H, Lee KB, Chie EK. Survival benefit of adjuvant chemoradiotherapy for positive or close resection margin after curative resection of pancreatic adenocarcinoma. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2020; 46:2122-2130. [PMID: 32782200 DOI: 10.1016/j.ejso.2020.07.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/30/2020] [Accepted: 07/19/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND This study was conducted to identify patients who may benefit from adjuvant chemoradiotherapy (CRT) for positive or close resection margin (RM) after curative resection of pancreatic adenocarcinoma. METHODS From 2004 to 2015, total of 472 patients with pancreatic adenocarcinoma underwent curative resection. After excluding patients with RM > 2 mm or unknown, remaining 217 patients were retrospectively analyzed. Forty-six (21.2%) patients were treated with adjuvant chemotherapy alone (CTx; mainly gemcitabine-based), 142 (65.4%) with adjuvant CRT (mainly upfront), and 29 (13.4%) patients didn't receive any adjuvant therapy (noTx group). RESULTS Locoregional recurrence rate was significantly lower in the CRT group (43.7%) than in the CTx group (71.7%) or noTx group (65.5%) (p = 0.001). Significant survival benefits of CRT over CTx (HR 0.602, p = 0.020 for overall survival (OS); HR 0.599, p = 0.016 for time to any recurrence (TTR)) were demonstrated in multivariate analysis. CRT group had more 5-year survivors than other groups. In the subgroup analysis, such benefits of adjuvant CRT over CTx was observed only in patients with head tumor & vascular RM > 0.5 mm, but not in patients with body/tail tumor or vascular RM ≤ 0.5 mm. In the CRT group, radiation dose≥54 Gy was significantly associated with better TTR and OS. CONCLUSIONS Adjuvant CRT could improve TTR and OS compared to adjuvant CTx alone in patients with close RM under 2 mm. Radiation dose escalation may be beneficial when feasible. Modern CRT regimen-based randomized evidence is needed for these high-risk patients.
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Affiliation(s)
- Byoung Hyuck Kim
- Department of Radiation Oncology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Kyubo Kim
- Department of Radiation Oncology, Ewha Womans University College of Medicine, Seoul, South Korea.
| | - Jin-Young Jang
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Wooil Kwon
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Hongbeom Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Kyung-Hun Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Do-Youn Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Haeryoung Kim
- Department of Pathology, Seoul National University College of Medicine, Seoul, South Korea
| | - Kyung Bun Lee
- Department of Pathology, Seoul National University College of Medicine, Seoul, South Korea
| | - Eui Kyu Chie
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, South Korea; Institute of Radiation Medicine, Medical Research Center, Seoul National University, Seoul, South Korea.
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Tempero MA, Malafa MP, Chiorean EG, Czito B, Scaife C, Narang AK, Fountzilas C, Wolpin BM, Al-Hawary M, Asbun H, Behrman SW, Benson AB, Binder E, Cardin DB, Cha C, Chung V, Dillhoff M, Dotan E, Ferrone CR, Fisher G, Hardacre J, Hawkins WG, Ko AH, LoConte N, Lowy AM, Moravek C, Nakakura EK, O'Reilly EM, Obando J, Reddy S, Thayer S, Wolff RA, Burns JL, Zuccarino-Catania G. Pancreatic Adenocarcinoma, Version 1.2019. J Natl Compr Canc Netw 2020; 17:202-210. [PMID: 30865919 DOI: 10.6004/jnccn.2019.0014] [Citation(s) in RCA: 249] [Impact Index Per Article: 62.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The NCCN Guidelines for Pancreatic Adenocarcinoma discuss the diagnosis and management of adenocarcinomas of the exocrine pancreas and are intended to assist with clinical decision-making. These NCCN Guidelines Insights discuss important updates to the 2019 version of the guidelines, focusing on postoperative adjuvant treatment of patients with pancreatic cancers.
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Affiliation(s)
| | | | | | | | | | - Amol K Narang
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | | | | | | | | | - Stephen W Behrman
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | - Al B Benson
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | - Ellen Binder
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | | | - Mary Dillhoff
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | | | | | - Jeffrey Hardacre
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | - William G Hawkins
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | - Andrew H Ko
- UCSF Helen Diller Family Comprehensive Cancer Center
| | | | | | | | | | | | | | - Sushanth Reddy
- University of Alabama at Birmingham Comprehensive Cancer Center
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Bouchart C, Navez J, Closset J, Hendlisz A, Van Gestel D, Moretti L, Van Laethem JL. Novel strategies using modern radiotherapy to improve pancreatic cancer outcomes: toward a new standard? Ther Adv Med Oncol 2020; 12:1758835920936093. [PMID: 32684987 PMCID: PMC7343368 DOI: 10.1177/1758835920936093] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 05/22/2020] [Indexed: 12/11/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) remains one of the most aggressive solid tumours with an estimated 5-year overall survival rate of 7% for all stages combined. In this highly resistant disease that is located in the vicinity of many radiosensitive organs, the role of radiotherapy (RT) and indications for its use in this setting have been debated for a long time and are still under investigation. Although a survival benefit has yet to be clearly demonstrated for RT, it is the only technique, other than surgery, that has been demonstrated to lead to local control improvement. The adjuvant approach is now strongly challenged by neoadjuvant treatments that could spare patients with rapidly progressive systemic disease from unnecessary surgery and may increase free margin (R0) resection rates for those eligible for surgery. Recently developed dose-escalated RT treatments, designed either to maintain full-dose chemotherapy or to deliver a high biologically effective dose, particularly to areas of contact between the tumour and blood vessels, such as hypofractionated ablative RT (HFA-RT) or stereotactic body RT (SBRT), are progressively changing the treatment landscape. These modern strategies are currently being tested in prospective clinical trials with encouraging preliminary results, paving the way for more effective treatment combinations using novel targeted therapies. This review summarizes the current literature regarding the use of RT for the treatment of primary PDAC, describes the limitations of conventional RT, and discusses the emerging role of dose-escalated RT and heavy-particle RT.
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Affiliation(s)
- Christelle Bouchart
- Department of Radiation-Oncology, Institut Jules Bordet, Boulevard de Waterloo, 121, Brussels, 1000, Belgium
| | - Julie Navez
- Department of Hepato-Biliary-Pancreatic Surgery, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean Closset
- Department of Hepato-Biliary-Pancreatic Surgery, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Alain Hendlisz
- Department of Gastroenterology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Dirk Van Gestel
- Department of Radiation-Oncology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Luigi Moretti
- Department of Radiation-Oncology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Luc Van Laethem
- Department of Gastroenterology, Hepatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Abstract
Pancreatic cancer is the fourth most common cause of cancer-related morality worldwide, and the prognosis remains poor despite aggressive therapy. Carbon ion radiotherapy has favorable radiobiological and physical characteristics in the treatment, including a higher linear energy transfer and higher relative biological effectiveness, which increase the cell kill while potentially reducing toxicities to nearby normal tissues. Although small, early clinical studies have shown promise in both the resectable and unresectable settings to improve local control and overall survival while minimizing toxicities. Currently, there are several trials, including 2 sponsored by institutions in the United States, investigating the role of carbon ion radiotherapy for the treatment of locally advanced pancreatic cancer.
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Mas L, Schwarz L, Bachet JB. Adjuvant chemotherapy in pancreatic cancer: state of the art and future perspectives. Curr Opin Oncol 2020; 32:356-363. [PMID: 32541325 DOI: 10.1097/cco.0000000000000639] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW The modalities of management of resectable pancreatic ductal adenocarcinoma (PDAC) have evolved in recent years with new practice guidelines on adjuvant chemotherapy and results of randomized phase III trials. The aim of this review is to describe the state of the art in this setting and to highlight future possible perspectives. RECENT FINDINGS Resectable PDAC is the tumor without vascular contact or a limited venous contact without vein irregularity. Several pathologic and biologic robust prognostic factors such as an R0 resection defined by a margin at least 1 mm have been validated. In phase III trials, the doublet gemcitabine-capecitabine provided a statistically significant, albeit modest overall survival benefit, but failed to show an improvement in relapse-free survival. Similarly, gemcitabine plus nab-paclitaxel did not increase disease-free survival. Modified FOLFIRINOX led to improved disease-free survival, overall survival, and metastasis-free survival, with acceptable toxicity. In the future, prognostic and/or predictive biomarkers could lead the optimization of therapeutic strategies and neoadjuvant treatment could become a standard of care in PDAC. SUMMARY After curative intent resection, modified FOLFIRINOX is the standard of care in adjuvant in fit patients with PDAC. Others regimens (monotherapy or gemcitabine-based) are an option in unfit patients.
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Affiliation(s)
- Léo Mas
- Department of Hepato-gastroenterology, Groupe Hospitalier Pitié Salpêtrière, Paris
| | - Lilian Schwarz
- Department of Digestive Surgery, Rouen University Hospital
- Department of Genomic and Personalized Medicine in Cancer and Neurological Disorders, Normandie University, UNIROUEN, UMR 1245 INSERM, Rouen University Hospital, Rouen
| | - Jean-Baptiste Bachet
- Department of Hepato-gastroenterology, Groupe Hospitalier Pitié Salpêtrière, Paris
- Sorbonne University, UPMC University, Paris, France
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Silvestris N, Brunetti O, Bittoni A, Cataldo I, Corsi D, Crippa S, D’Onofrio M, Fiore M, Giommoni E, Milella M, Pezzilli R, Vasile E, Reni M. Clinical Practice Guidelines for Diagnosis, Treatment and Follow-Up of Exocrine Pancreatic Ductal Adenocarcinoma: Evidence Evaluation and Recommendations by the Italian Association of Medical Oncology (AIOM). Cancers (Basel) 2020; 12:E1681. [PMID: 32599886 PMCID: PMC7352458 DOI: 10.3390/cancers12061681] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/21/2020] [Accepted: 06/22/2020] [Indexed: 12/12/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is the fourth leading cause of cancer-related death in women (7%) and the sixth in men (5%) in Italy, with a life expectancy of around 5% at 5 years. From 2010, the Italian Association of Medical Oncology (AIOM) developed national guidelines for several cancers. In this report, we report a summary of clinical recommendations of diagnosis, treatment and follow-up of PDAC, which may guide physicians in their current practice. A panel of AIOM experts in upper gastrointestinal cancer malignancies discussed the available scientific evidence supporting the clinical recommendations.
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Affiliation(s)
- Nicola Silvestris
- Medical Oncology Unit–IRCCS IstitutoTumori “Giovanni Paolo II” of Bari, 70124 Bari, Italy; (N.S.); (O.B.)
- Department of Biomedical Sciences and Human Oncology-University of Bari Medical School, 70124 Bari, Italy
| | - Oronzo Brunetti
- Medical Oncology Unit–IRCCS IstitutoTumori “Giovanni Paolo II” of Bari, 70124 Bari, Italy; (N.S.); (O.B.)
| | - Alessandro Bittoni
- Oncology Clinic, AOU Ospedali Riuniti, Polytechnic University of Marche, 60121 Ancona, Italy;
| | - Ivana Cataldo
- Department of Pathology, Hospital Cà Foncello of Treviso, 31100 Treviso, Italy;
| | - Domenico Corsi
- Medical Oncology Unit Azienda Ospedaliera San Giovanni Calibita Fatebene fratelli Roma, 00186 Roma, Italy;
| | - Stefano Crippa
- Division of Pancreatic Surgery, Vita-Salute University, San Raffaele Scientific Institute, 20132 Milan, Italy;
| | - Mirko D’Onofrio
- Department of Radiology, G. B. Rossi University Hospital, University of Verona, 37129 Verona, Italy;
| | - Michele Fiore
- Radiation Oncology, Campus Bio-Medico University, 00128 Rome, Italy;
| | - Elisa Giommoni
- Medical Oncology Unit, Department of Oncology and Robotic Surgery, AOU Careggi, 50139 Florence, Italy;
| | - Michele Milella
- Section of Medical Oncology, Department of Medicine, University of Verona and University Hospital Trust, 37129 Verona, Italy;
| | - Raffaele Pezzilli
- Department of Gastroenterology, San Carlo Hospital, 85100 Potenza, Italy;
| | - Enrico Vasile
- Division of Medical Oncology, Pisa University Hospital, 56124 Pisa, Italy;
| | - Michele Reni
- Department of Medical Oncology, IRCCS Ospedale San Raffaele, 20132 Milan, Italy
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Malakhov N, Lee A, Albert A, Lederman A, Byun J, Safdieh J, Schreiber D. Patterns of Care and Outcomes of Adjuvant Chemoradiation for Node-Positive Pancreatic Adenocarcinoma. J Gastrointest Cancer 2020; 51:506-514. [PMID: 31236851 DOI: 10.1007/s12029-019-00265-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE The literature has been conflicting on the superiority of adjuvant chemoradiation over chemotherapy for node-positive adenocarcinoma of the pancreas following definitive surgery. We aimed to evaluate the patterns of care and outcomes of these two treatment options using the National Cancer Database (NCDB). METHODS Patients diagnosed with non-metastatic, node-positive adenocarcinoma of the pancreas from 2006 to 2014 who received oncologic resection with negative margins were identified in the NCDB. Patient- and clinical-related factors were compared between those who received adjuvant chemotherapy alone (aC) versus adjuvant chemoradiation (aCRT). Univariable and multivariable logistic regression was performed to assess for predictors of adjuvant chemoradiation use. The Kaplan-Meier method was used to assess overall survival (OS) and Cox regression analysis was used to assess impact of covariables on OS. RESULTS There were 3609 patients who met the study criteria, of which 2988 (82.8%) received chemotherapy alone and 621 (17.2%) who received chemoradiation. Median follow up for living patients was 33.8 months (IQR 22-51). On multivariable logistic regression, those who received treatment in more recent years of diagnoses (OR 0.21-0.37, p < 0.001) were less likely to receive aCRT over aC. Two-year OS for those who received chemo alone was 44.9% and for chemoradiation was 42.6% (p = 0.169). This finding was sustained on multivariable survival analysis (HR 0.99, p = 0.867). CONCLUSIONS Adjuvant chemotherapy alone for adenocarcinoma of the pancreas is the predominant treatment of choice among US hospitals. There was no overall survival benefit noted in those who were treated with adjuvant chemoradiation.
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Affiliation(s)
- Nikita Malakhov
- Department of Radiation Oncology, SUNY Downstate Medical Center, 450 Clarkson Avenue, Mail Stop #1211, Brooklyn, NY, 11203, USA
- Department of Medicine, New York Presbyterian-Weill Cornell Medical Center, New York, NY, USA
| | - Anna Lee
- Department of Radiation Oncology, SUNY Downstate Medical Center, 450 Clarkson Avenue, Mail Stop #1211, Brooklyn, NY, 11203, USA.
- Department of Veterans Affairs, New York Harbor Healthcare System, Brooklyn, NY, USA.
| | - Ashley Albert
- Department of Radiation Oncology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Ariel Lederman
- Department of Radiation Oncology, SUNY Downstate Medical Center, 450 Clarkson Avenue, Mail Stop #1211, Brooklyn, NY, 11203, USA
- Department of Veterans Affairs, New York Harbor Healthcare System, Brooklyn, NY, USA
- Kings County Hospital Center, Brooklyn, NY, USA
| | - John Byun
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Joseph Safdieh
- Department of Radiation Oncology, SUNY Downstate Medical Center, 450 Clarkson Avenue, Mail Stop #1211, Brooklyn, NY, 11203, USA
- Kings County Hospital Center, Brooklyn, NY, USA
| | - David Schreiber
- Department of Radiation Oncology, SUNY Downstate Medical Center, 450 Clarkson Avenue, Mail Stop #1211, Brooklyn, NY, 11203, USA
- Summit Medical Group, Berkeley Heights, NJ, USA
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A systematic review and network meta-analysis of phase III randomised controlled trials for adjuvant therapy following resection of pancreatic ductal adenocarcinoma (PDAC). HPB (Oxford) 2020; 22:649-659. [PMID: 31894014 DOI: 10.1016/j.hpb.2019.12.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 11/28/2019] [Accepted: 12/02/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Several randomised controlled trials (RCTs) have reported various systemic adjuvant therapy regimens following resection of pancreatic ductal adenocarcinoma (PDAC). The most commonly applied include modified FOLFRINOX (mFFX), Gemcitabine/Capecitabine (GemCap) and S1, usually compared to gemcitabine (Gem) alone. However, many of these regimens have not been directly compared in RCTs. This network meta-analysis aims to characterise the impact of adjuvant therapies on overall and disease-free survival in patients having resection of PDAC. METHODS A systematic review was conducted using MEDLINE, EMBASE, Cochrane Central and American Society of Clinical Oncology (ASCO) abstracts to identify published phase III RCTs articles up to 9th May 2019 that examined adjuvant systemic therapy in resected pancreatic cancer. Data including study characteristics and outcomes including overall survival (OS) and disease-free survival (DFS) were extracted. Indirect comparisons of all regimens were simultaneously compared using random-effects network meta-analyses (NMA) which maintains randomisation within trials. RESULTS Twelve phase III RCTs involving 4947 patients and nine different regimens (5-Flourouracil/Folinic acid (5-FU/FA), Gemcitabine, Gemcitabine/Erlotinib (GemErl), GemCap), mFFX, S1, chemoradiotherapy (CRT), CRT with either 5-FU or Gemcitabine) were identified. S1 was ranked best for overall and disease-free survival followed by mFFX. Whilst there were no significant difference between S1 and mFFX for overall survival (mean difference: 1.6 months, p = 0.8), S1 had significantly longer disease-free survival than mFFX (mean difference: 2.8 months, p < 0.001). Furthermore, S1 was ranked best for lowest overall and haematological grade 3/4 toxicities. CONCLUSION This network meta-analysis demonstrates that chemotherapy with S1 or mFFX is superior to GemCap for adjuvant treatment for PDAC, improves survival after surgical resection and should be considered as reasonable standard treatment options in the adjuvant setting and as control arm for future adjuvant clinical trials.
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The Value of Total Lymph Nodes Examined and Number of Positive Lymph Nodes in Determining the Role of Adjuvant Radiation in Pancreatic Cancer Patients. Pancreas 2020; 49:435-441. [PMID: 32132517 DOI: 10.1097/mpa.0000000000001512] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES The aim of this study was to determine the survival benefits by adjuvant radiation therapy (RT) in pancreatic cancer patients with different total lymph nodes examined (TNE), number of positive lymph nodes (NPN), and lymph nodes ratio (LNR). METHODS National Cancer Database was queried for nonmetastatic pancreatic cancer patients from 2004 to 2015. Cox models were utilized. Interaction terms were applied to evaluate the effect of RT in different NPN, LNR, and margin strata. Multivariate analysis was performed. RESULTS Of 19,759 patients identified, 10,910 patients qualified. Compared with TNE of 1 to 9, TNE of 10 to 14, 15 to 19, 20 to 24, and 25 or greater had progressive overall survival (OS) benefits. Adjuvant RT had similar OS benefits among them. In negative margin patients, adjuvant RT improved OS when NPN was 2 to 3 (hazards ratio [HR], 0.84; P = 0.01) or LNR was 0.15 to 0.25 (HR, 0.79; P = 0.002). In positive margin patients, adjuvant RT nonsignificantly improved OS when NPN was 1 to 3 (HR, 0.89; P = 0.36) or when NPN was 4 or greater (HR, 0.79; P = 0.07). CONCLUSIONS Higher TNE correlates with better survival. Adjuvant RT may not compensate for inadequate lymph node dissection. Adjuvant RT improves survival in negative-margin patients with 2 to 3 positive lymph nodes or LNR of 0.15 to 0.25.
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Sakaguchi T, Satoi S, Yamamoto T, Yamaki S, Sekimoto M. The past, present, and future status of multimodality treatment for resectable/borderline resectable pancreatic ductal adenocarcinoma. Surg Today 2020; 50:335-343. [PMID: 31993761 PMCID: PMC7098925 DOI: 10.1007/s00595-020-01963-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 01/05/2020] [Indexed: 12/16/2022]
Abstract
A multimodal approach to treating pancreatic ductal adenocarcinoma (PDAC) is now widely accepted. Improvements in radiological assessment have enabled us to define resectability in detail. Multimodality treatment is essential for patients, especially for those with PDAC in the borderline resectable (BR) stage. Even for disease in a resectable (R) stage, adjuvant and neoadjuvant therapies have demonstrated beneficial outcomes in several trials and analyses. Thus, there is growing interest in optimization of the perioperative therapeutic strategy. We discuss the transition of resectability criteria and the global standard of adjuvant and neoadjuvant treatments for patients with R/BR-PDAC.
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Affiliation(s)
- Tatsuma Sakaguchi
- Department of Surgery, Kansai Medical University, 2-3-1, Shin-machi, Hirakata, Osaka, 573-1191, Japan
| | - Sohei Satoi
- Department of Surgery, Kansai Medical University, 2-3-1, Shin-machi, Hirakata, Osaka, 573-1191, Japan.
| | - Tomohisa Yamamoto
- Department of Surgery, Kansai Medical University, 2-3-1, Shin-machi, Hirakata, Osaka, 573-1191, Japan
| | - So Yamaki
- Department of Surgery, Kansai Medical University, 2-3-1, Shin-machi, Hirakata, Osaka, 573-1191, Japan
| | - Mitsugu Sekimoto
- Department of Surgery, Kansai Medical University, 2-3-1, Shin-machi, Hirakata, Osaka, 573-1191, Japan
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Clinical impact of additional therapy for residual pancreatic cancer. Surg Today 2019; 50:440-448. [PMID: 31650262 DOI: 10.1007/s00595-019-01900-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 10/10/2019] [Indexed: 12/15/2022]
Abstract
PURPOSE This study aimed to explore the prognostic significance of the resection margin (R) status of pancreatic ductal adenocarcinoma (PDAC) patients receiving neoadjuvant therapy (NAT) or adjuvant chemotherapy (AC). METHODS We retrospectively reviewed 427 consecutive patients, and the overall survival (OS) and disease-free survival (DFS) were analyzed based on the R status by a propensity score analysis (PSA). RESULTS The R0 ratio of the NAT (+) group was significantly higher than that of the NAT (-) group (97.2% vs. 69.6%, P < 0.0001). Local recurrence was well controlled in the NAT (+) group compared to the NAT (-) group (15.3% vs. 34.1%, P = 0.0013). The PSA revealed no significant survival difference between R0 and R1 resection among those treated with AC (median survival time [MST]: 43.0 vs. 33.3 months, matching hazard ratio [HR]: 1.212, P = 0.5708). Furthermore, the DFS in R0 and R1 resection followed by AC was identical (MST: 20.6 vs. 17.7 months, matching HR: 1.020, P = 0.9482). CONCLUSIONS NAT was a significant predictor of R0 resection. When patients completed AC, there were no marked differences in the OS or DFS between R0 and R1 resection. Our results demonstrated that the clinical impact of the R1 status has waned in the current era of PDAC management.
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Parmar A, Chaves-Porras J, Saluja R, Perry K, Rahmadian AP, Santos SD, Ko YJ, Berry S, Doherty M, Chan KKW. Adjuvant treatment for resected pancreatic adenocarcinoma: A systematic review and network meta-analysis. Crit Rev Oncol Hematol 2019; 145:102817. [PMID: 31955005 DOI: 10.1016/j.critrevonc.2019.102817] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 09/30/2019] [Accepted: 10/02/2019] [Indexed: 02/07/2023] Open
Abstract
Adjuvant chemotherapy has significantly improved outcomes following surgical resection for pancreatic adenocarcinoma; however, the optimal adjuvant strategy remains unclear. This systematic review and network meta-analysis was conducted to provide indirect comparative evidence across adjuvant chemotherapies. Electronic searches of EMBASE, MEDLINE, Cochrane and ASCO databases were conducted to identify eligible randomized controlled trials (RCT). Direct pairwise meta-analysis was conducted for disease-free survival (DFS), overall-survival (OS) and adverse events (AE). Network meta-analysis of DFS and OS was conducted to evaluate indirect comparisons. Ten publications of eleven RCT met eligibility criteria. Indirect DFS comparison demonstrated superiority of mFOLFIRINOX versus gemcitabine-capecitabine, gemcitabine-erlotinib and gemcitabine-nab-paclitaxel. S-1 demonstrated a DFS benefit versus gemcitabine-capecitabine, gemcitabine-erlotinib, gemcitabine-nab-paclitaxel. OS benefits were demonstrated for mFOLFIRINOX verus gemcitabine-erlotinib and for S-1 versus gemcitabine-based combination with erlotinib, capecitabine and nab-paclitaxel. In conclusion, mFOLFIRINOX is the preferred approach for adjuvant therapy. For mFOLFIRINOX-ineligible patients no additional benefit is seen with gemcitabine-nab-paclitaxel.
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Affiliation(s)
- Ambica Parmar
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jorge Chaves-Porras
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Ronak Saluja
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Kaitlyn Perry
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Amanda P Rahmadian
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - Yoo-Joung Ko
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Scott Berry
- Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Mark Doherty
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Kelvin K W Chan
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Canadian Centre for Applied Research in Cancer Control, Toronto, ON, Canada.
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Fenocchio E, Filippi R, Lombardi P, Quarà V, Milanesio M, Aimar G, Leone F, Aglietta M. Is There a Standard Adjuvant Therapy for Resected Pancreatic Cancer? Cancers (Basel) 2019; 11:E1547. [PMID: 31614884 PMCID: PMC6826876 DOI: 10.3390/cancers11101547] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 10/07/2019] [Accepted: 10/11/2019] [Indexed: 12/19/2022] Open
Abstract
Surgical resection remains the only treatment that offers a potential chance of long-term survival. Unfortunately, about 80% of patients treated with curative intent will develop recurrence. Since 2001, adjuvant therapy with gemcitabine or 5-fluorouracyle was recommended. This approach allows a median overall survival (OS) of around 23 months, and 5-year survival of 22%. In recent years, two phase-3 trials investigating new chemotherapy regimens resulted in considerably improved survival times. The doublet gemcitabine-capecitabine has shown improvement in OS from 25.5 to 28 months (p = 0.032) compared to gemcitabine, in the ESPAC-4 trial. Later, preliminary results of PRODIGE 24 trial presented at the 2018 ASCO meeting showed a superiority of a combination chemotherapy regimen with fluorouracil, leucovorin, irinotecan, and oxaliplatin (mFOLFIRINOX) when compared to gemcitabine alone, both in terms of median disease-free survival (21.6 vs. 12.8 months, p < 0.0001) and OS (54.4 vs. 35 months, p = 0.003). Contrary to chemotherapy, the role of adjuvant radiotherapy is still controversial, even in the case of R1 surgery. A randomized trial exploring the role of chemoradiotherapy in this setting is now ongoing in the US (RTOG-0848). Overall, the management of localized pancreatic adenocarcinoma is evolving. In this review, we summarize the current status and the most up-to-date developments in adjuvant treatment.
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Affiliation(s)
- Elisabetta Fenocchio
- Multidisciplinary Outpatient Oncology Clinic, Candiolo Cancer Institute, FPO-IRCCS, Strada Provinciale 142, km 3.95, 10060 Candiolo (TO), Italy.
| | - Roberto Filippi
- Department of Oncology, University of Turin Medical School, Strada Provinciale 142, km 3.95, 10060 Candiolo (TO), Italy.
| | - Pasquale Lombardi
- Department of Oncology, University of Turin Medical School, Strada Provinciale 142, km 3.95, 10060 Candiolo (TO), Italy.
| | - Virginia Quarà
- Department of Oncology, University of Turin Medical School, Strada Provinciale 142, km 3.95, 10060 Candiolo (TO), Italy.
| | - Michela Milanesio
- Department of Oncology, University of Turin Medical School, Strada Provinciale 142, km 3.95, 10060 Candiolo (TO), Italy.
| | - Giacomo Aimar
- Department of Oncology, University of Turin Medical School, Strada Provinciale 142, km 3.95, 10060 Candiolo (TO), Italy.
| | - Francesco Leone
- Division of Medical Oncology, Candiolo Cancer Institute, FPO-IRCCS, Strada Provinciale 142, km 3.95, 10060 Candiolo (TO), Italy.
- Department of Oncology, Azienda Sanitaria Locale di Biella, 13875 Ponderano (BI), Italy.
| | - Massimo Aglietta
- Department of Oncology, University of Turin Medical School, Strada Provinciale 142, km 3.95, 10060 Candiolo (TO), Italy.
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Petrillo A, Pappalardo A, Pompella L, Tirino G, Calabrese F, Laterza MM, Caterino M, Ventriglia A, Orditura M, Conzo G, Molino C, Ciardiello F, Biglietto M, De Vita F. Nab-paclitaxel plus gemcitabine as first line therapy in metastatic pancreatic cancer patients relapsed after gemcitabine adjuvant treatment. Med Oncol 2019; 36:83. [PMID: 31444639 DOI: 10.1007/s12032-019-1306-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 08/15/2019] [Indexed: 12/27/2022]
Abstract
Nab-paclitaxel plus gemcitabine (Nab-Gem) represents one of the standard regimen for first-line treatment of metastatic pancreatic adenocarcinoma (mPDAC). However, few data are available in mPDAC relapsed after gemcitabine as adjuvant treatment. Our study aims to evaluate the efficacy and feasibility of Nab-Gem as first-line treatment for mPDAC patients previously treated with adjuvant treatment. We retrospectively analyzed the safety and efficacy data of 36 patients, who received first-line Nab-Gem after gemcitabine as adjuvant treatment. All patients received gemcitabine after radical surgery. Median disease-free survival was 12 months (95% CI 9.7-14.3); at relapse, all patients received Nab-Gem. We observed an objective response rate and disease control rate of 11.1% and 63.9%, respectively. With a median follow-up of 47 months, median progression-free survival was 5 months (95% CI 1.0-9.0), whereas median overall survival (OS) was 13 months (95% CI 5.5-20.5). Median OS was higher in patients with a relapse ≥ 7 months after the end of adjuvant treatment than in patients relapsed < 7 months (14 vs. 8 months, respectively, p: 0.52). Our results show that first-line Nab-Gem is feasible and effective in patients previously treated with gemcitabine as adjuvant treatment.
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Affiliation(s)
- Angelica Petrillo
- Division of Medical Oncology, Department of Precision Medicine, University of Study of Campania "L. Vanvitelli", via Pansini n.5, 80131, Naples, Italy.
| | - Annalisa Pappalardo
- Division of Medical Oncology, Department of Precision Medicine, University of Study of Campania "L. Vanvitelli", via Pansini n.5, 80131, Naples, Italy
| | - Luca Pompella
- Division of Medical Oncology, Department of Precision Medicine, University of Study of Campania "L. Vanvitelli", via Pansini n.5, 80131, Naples, Italy
| | - Giuseppe Tirino
- Division of Medical Oncology, Department of Precision Medicine, University of Study of Campania "L. Vanvitelli", via Pansini n.5, 80131, Naples, Italy
| | | | - Maria Maddalena Laterza
- Division of Medical Oncology, Department of Precision Medicine, University of Study of Campania "L. Vanvitelli", via Pansini n.5, 80131, Naples, Italy
| | - Marianna Caterino
- Division of Medical Oncology, Department of Precision Medicine, University of Study of Campania "L. Vanvitelli", via Pansini n.5, 80131, Naples, Italy
| | - Anna Ventriglia
- Division of Medical Oncology, Department of Precision Medicine, University of Study of Campania "L. Vanvitelli", via Pansini n.5, 80131, Naples, Italy
| | - Michele Orditura
- Division of Medical Oncology, Department of Precision Medicine, University of Study of Campania "L. Vanvitelli", via Pansini n.5, 80131, Naples, Italy
| | - Giovanni Conzo
- Department of Cardiothoracic Sciences, University of Study of Campania "L. Vanvitelli", Via Sergio Pansini 5, 80131, Naples, Italy
| | - Carlo Molino
- Department of Oncological Surgery, A.O.R.N. "A. Cardarelli", Naples, Italy
| | - Fortunato Ciardiello
- Division of Medical Oncology, Department of Precision Medicine, University of Study of Campania "L. Vanvitelli", via Pansini n.5, 80131, Naples, Italy
| | - Maria Biglietto
- Division of Medical Oncology, AORN, "A Cardarelli", Naples, Italy
| | - Ferdinando De Vita
- Division of Medical Oncology, Department of Precision Medicine, University of Study of Campania "L. Vanvitelli", via Pansini n.5, 80131, Naples, Italy.
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Shen P, Huang KJ, Zhang CZ, Xiao L, Zhang T. Surgery with adjuvant or neoadjuvant treatment vs surgery alone for resectable pancreatic cancer: A network meta-analysis. World J Meta-Anal 2019; 7:309-322. [DOI: 10.13105/wjma.v7.i6.309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 06/04/2019] [Accepted: 06/10/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pancreatic cancer is one of the most common and lethal malignancies worldwide. The common treatment options for resectable pancreatic cancer include surgery alone, neoadjuvant chemotherapy (CT), neoadjuvant chemoradiotherapy (CRT), adjuvant CT, and adjuvant CRT. However, the optimal treatment is still controversial.
AIM To identify the most effective approach for pancreatic cancer using network meta-analysis.
METHODS Eligible studies were searched from PubMed, MEDLINE, EMBASE, Cochrane database, and Google scholar. We searched and included randomized controlled trials reporting on neoadjuvant and adjuvant therapies. For direct comparisons, standard pairwise meta-analysis was performed using the inverse variance DerSimonian-Laird random-effects model. For indirect comparisons, Bayesian network meta-analysis was used to combine direct and indirect evidence. We used relative hazard ratios (HRs) to estimate death difference of different treatments, and relative odds ratios (ORs) for toxic effects. Treatment effects were ranked based on their efficacy for improving survival or reducing toxicity using rankogram. The quality of evidence of estimates from direct comparison and network meta-analysis was evaluated following the GRADE approach.
RESULTS We included 13 high quality trials with 1591 participants in this network meta-analysis. Compared with surgery alone [pooled HR = 0.7, 95% confidence interval (CI): 0.62-0.79] and surgery with adjuvant CRT (pooled HR = 0.6, 95%CI: 0.54-0.72), surgery with adjuvant CT had a higher rate of overall survival. In contrast, standard pairwise meta-analysis showed a statistically significant survival advantage of surgery with adjuvant CT compared with surgery alone (pooled HR = 0.75, 95%CI: 0.63-0.89; P < 0.001). Rankogram showed that surgery with adjuvant CT was most likely to rank the best in terms of overall survival (probability: 94.2%), followed by surgery alone (probability: 5.8%). No significant differences in overall toxicity or haematological toxicity were found between all the therapies. High quality evidence supported surgery with adjuvant CT over surgery alone for increasing overall survival. Moderate quality evidence supported surgery with adjuvant CT over surgery with adjuvant CRT for increasing overall survival.
CONCLUSION Surgery with adjuvant CT prolongs overall survival compared with surgery alone and surgery with adjuvant CRT, suggesting surgery with adjuvant CT is the optimal treatment for resectable pancreatic cancer.
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Affiliation(s)
- Pu Shen
- Department of Anesthesia, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, Guangdong Province, China
| | - Kai-Jun Huang
- Department of General Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong Province, China
| | - Chuan-Zhao Zhang
- Department of General Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong Province, China
| | - Li Xiao
- Department of Anesthesia, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, Guangdong Province, China
| | - Tao Zhang
- Department of Anesthesia, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, Guangdong Province, China
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Guan S, Chen Y, Han Q, Deng G, Wang Y, Shi Y, Dai G. Preoperative CA19-9 levels predict disease-free survival and overall survival in pancreatic adenocarcinoma patients after resection. Transl Cancer Res 2019; 8:811-820. [PMID: 35116819 PMCID: PMC8798815 DOI: 10.21037/tcr.2019.04.24] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 04/26/2019] [Indexed: 01/12/2023]
Abstract
Background This study investigates the association between the preoperative serum CA19-9 and the effects of adjuvant chemotherapy (CT), and its impact on survival in patients undergoing curative resection for pancreatic adenocarcinoma (PAC). Methods From January 01, 2015 to June 30, 2017, we retrospectively reviewed 421 PAC patients who underwent radical resection. The association between preoperative CA19-9 and disease-free survival (DFS), and overall survival (OS) was analyzed using Kaplan-Meier method and Cox proportional hazards model. Results A total of 354 patients eligible for this study were classified into three groups according to preoperative CA19-9: G1 (≤87 U/mL), G2 (87–322 U/mL) and G3 (>322 U/mL), in tertiles. Multivariable analysis showed preoperative CA19-9 and adjuvant CT were both independent predictors of DFS and OS. Subgroup analyses showed the multivariable-adjusted hazard ratios (HR) of DFS for patients treated with adjuvant CT were 0.54 (95% CI, 0.33–0.86), 0.63 (95% CI, 0.40–0.97) and 0.32 (95% CI, 0.21–0.49) in G1, G2 and G3, respectively. A trend of decreasing HR of recurrence risk was observed in the higher preoperative CA 19-9 group treated with CT. Conclusions High preoperative CA19-9 is an emerging biomarker that identifies a more aggressive PAC subgroup, which might benefit more from postoperative CT.
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Affiliation(s)
- Shasha Guan
- Department of Medical Oncology, Chinese PLA General Hospital and Medical School of Chinese PLA, Beijing 100853, China
| | - Yang Chen
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Oncology, Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Quanli Han
- Department of Medical Oncology, Chinese PLA General Hospital and Medical School of Chinese PLA, Beijing 100853, China
| | - Guochao Deng
- Department of Medical Oncology, Chinese PLA General Hospital and Medical School of Chinese PLA, Beijing 100853, China
| | - Yanrong Wang
- Department of Medical Oncology, Chinese PLA General Hospital and Medical School of Chinese PLA, Beijing 100853, China
| | - Yan Shi
- Department of Medical Oncology, Chinese PLA General Hospital and Medical School of Chinese PLA, Beijing 100853, China
| | - Guanghai Dai
- Department of Medical Oncology, Chinese PLA General Hospital and Medical School of Chinese PLA, Beijing 100853, China
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Guha Majumdar A, Subramanian M. Hydroxychavicol from Piper betle induces apoptosis, cell cycle arrest, and inhibits epithelial-mesenchymal transition in pancreatic cancer cells. Biochem Pharmacol 2019; 166:274-291. [PMID: 31154000 DOI: 10.1016/j.bcp.2019.05.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 05/28/2019] [Indexed: 12/30/2022]
Abstract
Pancreatic cancer is a major cause of cancer-related mortality around the world. Currently, options for diagnosis and treatment are extremely limited, which culminates in a very high mortality rate. Intensive research spanning more than four decades has met several roadblocks in terms of improvement in overall survival. In this study, we have evaluated the effect of Hydroxychavicol (HC), a naturally occurring and abundantly isolatable allylarene from Piper betle leaves on pancreatic cancer cells. Our investigation reveals that HC inhibits proliferation and epithelial-mesenchymal transition (EMT) in pancreatic cancer cells. HC induces DNA damage, as evidenced by γ-H2AX, 53BP1 induction and comet assay, which further results in mitotic catastrophe and apoptosis. The apoptosis induced by HC is JNK pathway-dependent and caspase-mediated. HC also inhibits migration and invasion of pancreatic cancer cells via a generalized repression of genes involved in EMT. A quantitative real time PCR-based array revealed at least 14 different genes to be differentially expressed upon HC treatment in pancreatic cancer cells. These results show significant potential of HC as an anticancer agent against pancreatic cancer.
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Affiliation(s)
- Ananda Guha Majumdar
- Bio-Organic Division, Bhabha Atomic Research Centre, Trombay, Mumbai 400 085, India
| | - Mahesh Subramanian
- Bio-Organic Division, Bhabha Atomic Research Centre, Trombay, Mumbai 400 085, India; Homi Bhabha National Institute, Anushaktinagar, Mumbai 400 094, India.
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Fitzgerald TL, Hunter L, Mosquera C, Jindal C, Biswas T, Zervos E, Efird JT. A simple matrix to predict treatment success and long-term survival among patients undergoing pancreatectomy. HPB (Oxford) 2019; 21:204-211. [PMID: 30087052 DOI: 10.1016/j.hpb.2018.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 05/16/2018] [Accepted: 07/09/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND A more accurate measure of long-term survival among patients who have undergone a successful resection for pancreatic adenocarcinoma may be computed by accounting for time already survived during the initial treatment window. METHODS Patients diagnosed with pancreatic adenocarcinoma, from 2004 through 2013, were identified from the American College of Surgeons National Cancer Database (NCDB). A risk-stratification matrix was constructed including age, histopathologic factors and the use of adjuvant therapy, given successful treatment and survival at 3-month following diagnosis. RESULTS A total of 25,897 patients (50% male, 53% >65 years of age) presented with stage I-III pancreatic cancer. The majority of patients had tumors >2 cm size (82%), grade I/II (65%), lymphatic invasion (LI) (66%), and negative margins (76%). A survival advantage for adjuvant therapy was observed among all patients, independent of their risk-profile. For example, a patient ≤65 years of age, with early stage cancer (size ≤2 cm, grade I/II, -ve LI, -ve margins) who received adjuvant therapy had a 62% probability of being alive beyond three years (95%CI = 59%-66%). In contrast, the survival probability decreased to 53% (95%CI = 59%-66%) without adjuvant therapy. CONCLUSIONS These results provide surgeons and patients with more accurate information regarding long-term survival, as well as the benefit of opting for adjuvant therapy after successful pancreatic surgery.
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Affiliation(s)
| | - Lucas Hunter
- Department of Surgical Oncology, Brody School of Medicine, Greenville, NC, USA
| | - Catalina Mosquera
- Department of Surgical Oncology, Brody School of Medicine, Greenville, NC, USA; Vidant Cancer Care, Greenville, NC, USA
| | - Charulata Jindal
- Centre for Clinical Epidemiology and Biostatistics (CCEB), School of Medicine and Public Health, The University of Newcastle (UoN), Newcastle, 2308, Australia
| | - Tithi Biswas
- Department of Radiation Oncology, University Hospitals, Case Western Reserve University, Cleveland, OH, USA
| | | | - Jimmy T Efird
- Centre for Clinical Epidemiology and Biostatistics (CCEB), School of Medicine and Public Health, The University of Newcastle (UoN), Newcastle, 2308, Australia.
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Abstract
OBJECTIVE The incidence of pancreatic adenocarcinoma (PA) approximates its prevalence, as the malignancy is almost consistently fatal within a year. Although the currently available adjuvant therapy seems to provide survival benefit, it is only moderate, and the standard regimen has not yet been established. Therefore, more biological resources to investigate the PA are needed. METHODS Here, we established and characterized 10 human pancreatic cancer cell lines derived from primary tumor mass. Whole exome sequencing technique was used to identify driver mutations and aberrant pathways in each cell line. RESULTS Five anticancer drugs were treated to find half maximal effective concentration (EC50), and the response was analyzed in reference to mutational status. Frame shift mutations in ARID1A gene and HER2 amplification were mutually related to better response to the anticancer drugs. In contrast, frame shift mutation in MSH6 gene was associated with resistance to anticancer drugs. CONCLUSIONS In summary, we established 10 pancreatic cancer cell lines and integrated various molecular aberrations and features of pancreatic cancer cells. Our biological resources are expected to contribute to facilitating research on PA.
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Ettrich TJ, Berger AW, Perkhofer L, Daum S, König A, Dickhut A, Wittel U, Wille K, Geissler M, Algül H, Gallmeier E, Atzpodien J, Kornmann M, Muche R, Prasnikar N, Tannapfel A, Reinacher-Schick A, Uhl W, Seufferlein T. Neoadjuvant plus adjuvant or only adjuvant nab-paclitaxel plus gemcitabine for resectable pancreatic cancer - the NEONAX trial (AIO-PAK-0313), a prospective, randomized, controlled, phase II study of the AIO pancreatic cancer group. BMC Cancer 2018; 18:1298. [PMID: 30594153 PMCID: PMC6311014 DOI: 10.1186/s12885-018-5183-y] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 12/04/2018] [Indexed: 12/18/2022] Open
Abstract
Background Even clearly resectable pancreatic cancer still has an unfavorable prognosis. Neoadjuvant or perioperative therapies might improve the prognosis of these patients. Thus, evaluation of perioperative chemotherapy in resectable pancreatic cancer in a prospective, randomized trial is warranted. A substantial improvement in overall survival of patients with metastatic pancreatic cancer with FOLFIRINOX and nab-paclitaxel/gemcitabine vs standard gemcitabine has been demonstrated in phase III-trials. Indeed nab-paclitaxel/gemcitabine has a more favorable toxicity profile compared to the FOLFIRINOX protocol and appears applicable in a perioperative setting. Methods NEONAX is an interventional, prospective, randomized, controlled, open label, two sided phase II study with an unconnected analysis of the results in both experimental arms against a fixed survival probability (38% at 18 months with adjuvant gemcitabine), NCT02047513. NEONAX will enroll 166 patients with resectable pancreatic ductal adenocarcinoma (≤ cT3, N0 or N1, cM0) in two arms: Arm A (perioperative arm): 2 cycles nab-paclitaxel (125 mg/m2)/gemcitabine (1000 mg/m2, d1, 8 and 15 of an 28 day-cycle) followed by tumor surgery followed by 4 cycles nab-paclitaxel/gemcitabine, Arm B (adjuvant arm): tumor surgery followed by 6 cycles nab-paclitaxel/gemcitabine. The randomization (1:1) is eminent to avoid allocation bias between the groups. Randomization is stratified for tumor stage (ct1/2 vs. cT3) and lymph node status (cN0 vs. cN1). Primary objective is disease free survival (DFS) at 18 months after randomization. Key secondary objectives are 3-year overall survival (OS) rate and DFS rate, progression during neoadjuvant therapy, R0 and R1 resection rate, quality of life and correlation of DFS, OS and tumor regression with pharmacogenomic markers, tumor biomarkers and molecular analyses (ctDNA, transcriptome, miRNA-arrays). In addition, circulating tumor-DNA will be analyzed in patients with the best and the worst responses to the neoadjuvant treatment. The study was initiated in March 2015 in 26 centers for pancreatic surgery in Germany. Discussion The NEONAX trial is an innovative study on resectable pancreatic cancer and currently one of the largest trials in this field of research. It addresses the question of the role of intensified perioperative treatment with nab-paclitaxel plus gemcitabine in resectable pancreatic cancers to improve disease-free survival and offers a unique potential for translational research. Trial registration ClinicalTrials.gov: NCT02047513, 08/13/2014. Electronic supplementary material The online version of this article (10.1186/s12885-018-5183-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Thomas J Ettrich
- Department of Internal Medicine I, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Andreas W Berger
- Department of Internal Medicine I, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Lukas Perkhofer
- Department of Internal Medicine I, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Severin Daum
- Department of Gastroenterology, Infectious Diseases and Rheumatology, Charité University Medicine Berlin, Hindenburgdamm 30, 12200, Berlin, Germany
| | - Alexander König
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center Goettingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - Andreas Dickhut
- Department of Oncology/Hematology, Fulda Hospital, Pacelliallee 4, 36043, Fulda, Germany
| | - Uwe Wittel
- Department of General and Visceral Surgery, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Kai Wille
- Department of Hematology and medical oncology, Johannes-Wesling-Klinikum Minden, Hans-Nolte-Straße 1, 32429, Minden, Germany
| | - Michael Geissler
- Department of Internal Medicine, Oncology/Hematology, Gastroenterology, Esslingen Hospital, Hirschlandstr. 97, 73730 Esslingen, Esslingen, Germany
| | - Hana Algül
- Department of Internal Medicine II, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Eike Gallmeier
- Department of Gastroenterology and Endocrinology, University of Marburg, Baldingerstraße, 35043, Marburg, Germany
| | - Jens Atzpodien
- Department of Medical Oncology and Hematology, Niels-Stensen-Kliniken, Alte Rothenfelder Str. 23, 49124, Georgsmarienhütte, Germany
| | - Marko Kornmann
- Department of General and Visceral Surgery, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Rainer Muche
- Institute of Epidemiology and Medical Biometry, University of Ulm, Schwabstrasse 13, 89081, Ulm, Germany
| | - Nicole Prasnikar
- Department of Oncologie, Asklepios Klinik Barmbek, Rübenkamp 220, 22291, Hamburg, Germany
| | - Andrea Tannapfel
- Department of Pathology, Ruhr-University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Anke Reinacher-Schick
- Department of Internal Medicine, Ruhr-University Bochum, Gudrunstr. 56, 44791, Bochum, Germany
| | - Waldemar Uhl
- Department of Surgery, Ruhr-University Bochum, Gudrunstr. 56, 44791, Bochum, Germany
| | - Thomas Seufferlein
- Department of Internal Medicine I, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany.
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Torgeson A, Tao R, Garrido-Laguna I, Willen B, Dursteler A, Lloyd S. Large database utilization in health outcomes research in pancreatic cancer: an update. J Gastrointest Oncol 2018; 9:996-1004. [PMID: 30603118 PMCID: PMC6286942 DOI: 10.21037/jgo.2018.05.15] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 05/16/2018] [Indexed: 12/18/2022] Open
Abstract
We sought to review published aggregate dataset studies on pancreatic cancer in the national and international settings, discuss the advantages and disadvantages these datasets possess, and possible future directions. A combination of Google Scholar, PubMed, and MEDLINE were used with search terms "pancreatic cancer" + "resectable" + "national cancer database", "pancreatic cancer" + "unresectable" + "national cancer database" and more broadly "borderline resectable pancreatic cancer", "locally advanced pancreatic cancer", "unresectable pancreatic cancer", and "resectable pancreatic cancer". Original articles and abstracts from this search were included, including data from the Surveillance, Epidemiology, and End Results (SEER) database, National Cancer Database (NCDB), and SEER-Medicare within the United States (US), as well as international database studies. Multiple database studies have been published regarding the role for radiotherapy in resected pancreatic cancer (n=6), the timing of additional therapy in resectable pancreatic cancer (n=4), and the role for radiotherapy and resection in locally advanced pancreatic cancer (LAPC) (n=4). Studies from both SEER and NCDB found a survival benefit to post-operative radiotherapy. In resectable pancreatic cancer, neoadjuvant treatment was found to be superior to adjuvant (NCDB). Chemoradiotherapy was found to be more beneficial than chemotherapy alone in LAPC, and patients who received highly-conformal or stereotactic body radiotherapy (SBRT) had improved survival compared to either conformal radiotherapy or chemotherapy alone. These studies also found that up to 10% of patients underwent resection, with a 90% margin-negative rate, and either one-half to one-third the risk of death of non-surgical patients. Criticism of large datasets includes lack of granularity of performance status, diagnosis, treatment, and outcomes-related data compared to properly administered prospective trials, as well as cross-over between treatment arms that cannot be accounted for, and concerns over quality of data represented. The US has witnessed a growing number of comparative effectiveness studies in pancreatic cancer. When taken together, certain themes emerge that are consistent with both single-institution data and clinical trials. These studies have also provided insight into questions not readily answerable by clinical trials. However, they require caution in interpretation.
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Affiliation(s)
- Anna Torgeson
- Department of Radiation Oncology, University of Utah, Salt Lake City, Utah, USA
| | - Randa Tao
- Department of Radiation Oncology, University of Utah, Salt Lake City, Utah, USA
| | | | - Benjamin Willen
- Wright State University, Boonshoft School of Medicine, Dayton, Ohio, USA
| | - Amy Dursteler
- The University of Texas Medical School, Houston, Texas, USA
| | - Shane Lloyd
- Department of Radiation Oncology, University of Utah, Salt Lake City, Utah, USA
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50
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Neuzillet C, Gaujoux S, Williet N, Bachet JB, Bauguion L, Colson Durand L, Conroy T, Dahan L, Gilabert M, Huguet F, Marthey L, Meilleroux J, de Mestier L, Napoléon B, Portales F, Sa Cunha A, Schwarz L, Taieb J, Chibaudel B, Bouché O, Hammel P. Pancreatic cancer: French clinical practice guidelines for diagnosis, treatment and follow-up (SNFGE, FFCD, GERCOR, UNICANCER, SFCD, SFED, SFRO, ACHBT, AFC). Dig Liver Dis 2018; 50:1257-1271. [PMID: 30219670 DOI: 10.1016/j.dld.2018.08.008] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 08/06/2018] [Accepted: 08/07/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND This document is a summary of the French intergroup guidelines regarding the management of pancreatic adenocarcinoma (PA), updated in July 2018. DESIGN This collaborative work was produced under the auspices of all French medical and surgical societies involved in the management of PA. It is based on the previous guidelines, recent literature review and expert opinions. Recommendations were graded in three categories, according to the level of evidence. RESULTS Over the last seven years, significant changes in PA management have been implemented in clinical practice. Imaging/staging: diffusion magnetic resonance imaging is useful before surgery to rule out small liver metastases. SURGERY centralization of pancreatic surgery in expert centers is associated with a decreased postoperative mortality. Adjuvant chemotherapy: modified FOLFIRINOX in fit patients, or gemcitabine, or 5-FU, or gemcitabine plus capecitabine, to be discussed on a case-by-case basis. Locally advanced PA: no survival benefit of chemoradiotherapy. Metastatic PA: FOLFIRINOX and gemcitabine plus nab-paclitaxel combination are first-line standards in fit patients; second-line with 5FU/nal-IRI or 5FU/oxaliplatin combination after first-line gemcitabine. CONCLUSION Guidelines for management of PA are continuously evolving and need to be regularly updated. This constant progress is made possible through clinical and translational research. However, as each individual case is particular, they cannot substitute to multidisciplinary tumor board discussion.
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Affiliation(s)
- Cindy Neuzillet
- Department of Medical Oncology, Curie Institute, Versailles Saint-Quentin University (UVSQ), Saint-Cloud, France.
| | - Sébastien Gaujoux
- Department of Digestive, Hepato-Biliary and Pancreatic Surgery, Cochin Hospital, AP-HP, Paris Descartes Faculty of Medicine, Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - Nicolas Williet
- Hepato-Gastroenterology Department, University Hospital of Saint-Etienne, Saint Priest en Jarez, France
| | - Jean-Baptiste Bachet
- Hepato-Gastroenterology Department, Pitié Salpétrière University Hospital, AP-HP, Paris Cedex 13, France
| | - Lucile Bauguion
- Hepato-Gastroenterology Department, Departmental Hospital Center, La Roche sur Yon, France
| | - Laurianne Colson Durand
- Department of Radiotherapy, Henri Mondor Hospital, AP-HP, Université Paris Est Creteil, Créteil, France
| | - Thierry Conroy
- Department of Medical Oncology, Lorraine Institute of Oncology and Lorraine University, Vandoeuvre-lès-Nancy Cedex, France
| | - Laetitia Dahan
- Digestive Oncology Department, "DACCORD" (Digestif, Anatomie pathologique, Chirurgie, CISIH, Oncologie, Radiothérapie, Dermatologie) pole, CHU Timone, Marseille Cedex 05, France
| | - Marine Gilabert
- Paoli Calmettes Institute, Department of Medical Oncology and Cancer Research Center of Marseille (CRCM), INSERM U1068 Stress Cell, Aix-Marseille University, Marseille, France
| | - Florence Huguet
- Department of Oncology and Radiotherapy, Tenon Hospital, East Paris University Hospitals, AP-HP, Paris Sorbonne University, Paris, France
| | - Lysiane Marthey
- Gastroenterology Department, Béclère Hospital, AP-HP, Clamart, France
| | - Julie Meilleroux
- Pathology Department, Toulouse University Hospital, Toulouse, France
| | - Louis de Mestier
- Department of Gastroenterology-Pancreatology, Beaujon Hospital, APHP, Paris 7 University, Clichy, France
| | - Bertrand Napoléon
- Jean Mermoz Private Hospital, Ramsay Générale de Santé, Lyon, France
| | - Fabienne Portales
- Digestive Oncology Department, Regional Institute of Cancer, Montpellier, France
| | - Antonio Sa Cunha
- INSERM UMR 935, Paul Brousse Hospital, Hepatobiliary Center, AP-HP, Université Paris-Sud, Université Paris-Saclay, Villejuif, France
| | - Lilian Schwarz
- Department of Digestive Surgery, Hôpital Charles Nicolle, Rouen University Hospital, Rouen, France and Genomic and Personalized Medicine in Cancer and Neurological Disorders, UMR 1245 INSERM, Rouen University, France
| | - Julien Taieb
- Hepato-Gastroenterology and Digestive Oncology Department, Georges Pompidou European Hospital, AP-HP, Paris, France
| | - Benoist Chibaudel
- Department of Medical Oncology, Franco-British Institute, Levallois-Perret, France
| | - Olivier Bouché
- Hepato-Gastroenterology and Digestive Oncology Department, Robert Debré University Hospital, Avenue Général Koenig, 51092 Reims Cedex, France
| | - Pascal Hammel
- Department of Digestive Oncology, Beaujon University Hospital (AP-HP), Paris VII Diderot University, Clichy-la-Garenne, France.
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