1
|
Morganti AG, Cellini F, Buwenge M, Arcelli A, Alfieri S, Calvo FA, Casadei R, Cilla S, Deodato F, Di Gioia G, Di Marco M, Fuccio L, Bertini F, Guido A, Herman JM, Macchia G, Maidment BW, Miller RC, Minni F, Passoni P, Valentini C, Re A, Regine WF, Reni M, Falconi M, Valentini V, Mattiucci GC. Adjuvant chemoradiation in pancreatic cancer: impact of radiotherapy dose on survival. BMC Cancer 2019; 19:569. [PMID: 31185957 PMCID: PMC6560746 DOI: 10.1186/s12885-019-5790-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 05/31/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND To evaluate the impact of radiation dose on overall survival (OS) in patients treated with adjuvant chemoradiation (CRT) for pancreatic ductal adenocarcinoma (PDAC). METHODS A multicenter retrospective analysis on 514 patients with PDAC (T1-4; N0-1; M0) treated with surgical resection with macroscopically negative margins (R0-1) followed by adjuvant CRT was performed. Patients were stratified into 4 groups based on radiotherapy doses (group 1: < 45 Gy, group 2: ≥ 45 and < 50 Gy, group 3: ≥ 50 and < 55 Gy, group 4: ≥ 55 Gy). Adjuvant chemotherapy was prescribed to 141 patients. Survival functions were plotted using the Kaplan-Meier method and compared through the log-rank test. RESULTS Median follow-up was 35 months (range: 3-120 months). At univariate analysis, a worse OS was recorded in patients with higher preoperative Ca 19.9 levels (≥ 90 U/ml; p < 0.001), higher tumor grade (G3-4, p = 0.004), R1 resection (p = 0.004), higher pT stage (pT3-4, p = 0.002) and positive nodes (p < 0.001). Furthermore, patients receiving increasing doses of CRT showed a significantly improved OS. In groups 1, 2, 3, and 4, median OS was 13.0 months, 21.0 months, 22.0 months, and 28.0 months, respectively (p = 0.004). The significant impact of higher dose was confirmed by multivariate analysis. CONCLUSIONS Increasing doses of CRT seems to favorably impact on OS in adjuvant setting. The conflicting results of randomized trials on adjuvant CRT in PDAC could be due to < 45 Gy dose generally used.
Collapse
Affiliation(s)
- Alessio G. Morganti
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, S. Orsola-Malpighi Hospital, via Giuseppe Massarenti 9, 40138 Bologna, Italy
| | - Francesco Cellini
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Istituto di Radiologia, Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Roma, Italy
| | - Milly Buwenge
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, S. Orsola-Malpighi Hospital, via Giuseppe Massarenti 9, 40138 Bologna, Italy
| | - Alessandra Arcelli
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, S. Orsola-Malpighi Hospital, via Giuseppe Massarenti 9, 40138 Bologna, Italy
| | - Sergio Alfieri
- Istituto di Clinica Chirurgica, Fondazione Policlinico A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Roma, Italy
| | - Felipe A. Calvo
- Department of Oncology, Hospital General Universitario Gregorio Marañón, Complutense University, Madrid, Spain
| | - Riccardo Casadei
- Department of Medical and Surgical Sciences – DIMEC, University of Bologna, Bologna, Italy
| | - Savino Cilla
- Unit of Medical Physics, Fondazione Giovanni Paolo II, Campobasso, Italy
| | | | - Giancarmine Di Gioia
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, S. Orsola-Malpighi Hospital, via Giuseppe Massarenti 9, 40138 Bologna, Italy
| | - Mariacristina Di Marco
- Department of Experimental, Diagnostic, and Specialty Medicine - DIMES, Sant’Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Lorenzo Fuccio
- Department of Medical and Surgical Sciences – DIMEC, University of Bologna, Bologna, Italy
| | - Federica Bertini
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, S. Orsola-Malpighi Hospital, via Giuseppe Massarenti 9, 40138 Bologna, Italy
| | - Alessandra Guido
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, S. Orsola-Malpighi Hospital, via Giuseppe Massarenti 9, 40138 Bologna, Italy
| | - Joseph M. Herman
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland USA
| | | | - Bert W. Maidment
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia USA
| | - Robert C. Miller
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN USA
| | - Francesco Minni
- Department of Medical and Surgical Sciences – DIMEC, University of Bologna, Bologna, Italy
| | | | - Chiara Valentini
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Alessia Re
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Istituto di Radiologia, Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Roma, Italy
| | - William F. Regine
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD USA
| | | | - Massimo Falconi
- Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Hospital, University “Vita e Salute”, Milan, Italy
| | - Vincenzo Valentini
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Istituto di Radiologia, Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Roma, Italy
| | - Gian Carlo Mattiucci
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Istituto di Radiologia, Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Roma, Italy
| |
Collapse
|
2
|
Mattiucci GC, Morganti AG, Cellini F, Buwenge M, Casadei R, Farioli A, Alfieri S, Arcelli A, Bertini F, Calvo FA, Cammelli S, Fuccio L, Giaccherini L, Guido A, Herman JM, Macchia G, Maidment BW, Miller RC, Minni F, Regine WF, Reni M, Partelli S, Falconi M, Valentini V. Prognostic Impact of Presurgical CA19-9 Level in Pancreatic Adenocarcinoma: A Pooled Analysis. Transl Oncol 2018; 12:1-7. [PMID: 30237099 PMCID: PMC6143718 DOI: 10.1016/j.tranon.2018.08.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 08/26/2018] [Accepted: 08/29/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND: Presurgical carbohydrate antigen 19-9 (CA19-9) level predicts overall survival (OS) in resected pancreatic adenocarcinoma (PaC). The aim of this pooled analysis was to evaluate if presurgical CA19-9 level can also predict local control (LC) and distant metastasis-free survival (DMFS). METHODS: Seven hundred patients with PaC from eight institutions who underwent surgical resection ± adjuvant treatment between 2000 and 2014 were analyzed. Patients were divided based on four presurgical CA19-9 level cutoffs (5, 37, 100, 353 U/ml). Weibull regression model to identify independent predictors of OS on 404 patients with complete information was fitted. RESULTS: Median follow-up was 17 months (range: 2-225 months). Univariate analysis showed a better prognosis in pT1-2, pN0, diameter <30 mm, or grade 1 tumors and in patients undergoing R0 resection, distal pancreatectomy, or adjuvant chemotherapy and with lower CA19-9 levels. Five-year OS, LC, and DMFS were as follows: CA19-9 <5.0: 5.7%, 47.2%, 17.0%; CA19-9 5.1-37.0: 37.9%, 63.3%, 46.0%; CA19-9 37.1-100.0: 27.1%, 59.4%, 39.0%; CA19-9 100.1-353.0: 17.4%, 43.4%, 26.7%; CA19-9 >353.1: 10.9%, 50.2%, and 23.4%, respectively. At multivariate analysis, CA19-9 >100 and <353 level (P=.002), CA19-9 ≥353.1 (P<.001) level, G3 tumor (P=.002), and tumor diameter >30 mm (P<.001) correlated with worse OS. Patients treated with postoperative chemoradiation doses >50.0 Gy showed improved OS (P<.001). CONCLUSION: Presurgical CA19-9 predicts both OS and pattern of failure. Therefore, CA19-9 should be included in predictive models in order to customize treatments based on prognostic factors. Moreover, future studies should stratify patients according to presurgical CA19-9 level.
Collapse
Affiliation(s)
- Gian Carlo Mattiucci
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Istituto di Radiologia, Fondazione Policlinico A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Roma, Italia
| | - Alessio G Morganti
- Radiation Oncology Center, Dept of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, Bologna, Italy
| | - Francesco Cellini
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Istituto di Radiologia, Fondazione Policlinico A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Roma, Italia.
| | - Milly Buwenge
- Radiation Oncology Center, Dept of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, Bologna, Italy
| | - Riccardo Casadei
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Andrea Farioli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Sergio Alfieri
- Istituto di Clinica Chirurgica, Fondazione Policlinico A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Roma, Italia
| | - Alessandra Arcelli
- Radiation Oncology Center, Dept of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, Bologna, Italy
| | - Federica Bertini
- Radiation Oncology Center, Dept of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, Bologna, Italy
| | - Felipe A Calvo
- Department of Oncology, Hospital General Universitario Gregorio Marañón, Complutense University, Madrid, Spain
| | - Silvia Cammelli
- Radiation Oncology Center, Dept of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, Bologna, Italy
| | - Lorenzo Fuccio
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Lucia Giaccherini
- Radiation Oncology Center, Dept of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, Bologna, Italy
| | - Alessandra Guido
- Radiation Oncology Center, Dept of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, Bologna, Italy
| | - Joseph M Herman
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Mariland, USA
| | - Gabriella Macchia
- Radiotherapy Unit, General Oncology Unit, Fondazione Giovanni Paolo II, Campobasso, Italy
| | - Bert W Maidment
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia, USA
| | - Robert C Miller
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Francesco Minni
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - William F Regine
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Michele Reni
- Department of Medical Oncology, IRCCS Ospedale S. Raffaele, Milan, Italy
| | - Stefano Partelli
- Department of Medical Oncology, IRCCS Ospedale S. Raffaele, Milan, Italy
| | - Massimo Falconi
- Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Hospital, University "Vita e Salute", Milan, Italy
| | - Vincenzo Valentini
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Istituto di Radiologia, Fondazione Policlinico A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Roma, Italia
| |
Collapse
|
3
|
Macchia G, Valentini V, Mattiucci GC, Mantini G, Alfieri S, Digesù C, Deodato F, Trodella L, Doglietto GB, Cellini N, Morganti AG. Preoperative Chemoradiation and Intra-Operative Radiotherapy for Pancreatic Carcinoma. TUMORI JOURNAL 2018; 93:53-60. [PMID: 17455872 DOI: 10.1177/030089160709300110] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Aims and background In recent years, preoperative chemoradiation has received growing interest for the treatment of locally advanced pancreatic cancer. In an attempt to improve resectability and disease control, we used preoperative radiation therapy and concomitant 5-fluorouracil in a combined modality therapy protocol. The aim of the study was to evaluate definitive results in terms of toxicity, response and clinical outcome. Material and methods Twenty-eight patients with unresectable (cT4,19 patients) or resectable (cT3, 9 patients) nonmetastatic pancreatic tumors received radiotherapy (39.6 Gy) plus 5-fluorouracil (continuous infusion, days 1-4 at 1000 mg/m2/day). After 4 weeks, patients were evaluated for surgical resection. In 9 resected patients, electron-beam intra-operative radiotherapy (10 Gy) was given before reconstruction. Thereafter, in resected patients, adjuvant chemotherapy was prescribed. Results During chemoradiation, 1 patient (3.6%) developed grade 3 acute gastrointestinal toxicity and 2 patients (7.1%) developed grade 3 hematological toxicity. Three of 19 patients with unresectable tumors had tumor downstaging (15.8%). Two patients showed partial response (response rate, 7.1%; 95% CI, 0.2-25.3) and 4 patients (14.3%) had minimal tumor response. Four patients (14.3%) showed progressive disease after chemoradiation. One postoperative death was recorded. The median survival time was 11.3 months (20.5 and 9.0 months in resected and unresected patients, respectively). Only one local failure was recorded in 8 patients resected with negative margins. Conclusions Although the response rate is still low, our preliminary results suggest that preoperative 5-fluorouracil chemoradiation is well tolerated and may result in tumor downstaging. Delivery of intra-operative radiotherapy seems to be associated with a low rate of local recurrences.
Collapse
Affiliation(s)
- Gabriella Macchia
- Unità Operativa di Radioterapia, Universitti Cattolica del S. Cuore, Campobasso.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
4
|
Pancreatic Cancer: 80 Years of Surgery-Percentage and Repetitions. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2016; 2016:6839687. [PMID: 27847403 PMCID: PMC5099466 DOI: 10.1155/2016/6839687] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 06/01/2016] [Indexed: 12/18/2022]
Abstract
Objective. The incidence of pancreatic cancer is estimated to be 48,960 in 2015 in the US and projected to become the second and third leading causes of cancer-related deaths by 2030. The mean costs in 2015 may be assumed to be $79,800 per patient and for each resection $164,100. Attempt is made to evaluate the results over the last 80 years, the number of survivors, and the overall survival percentage. Methods. Altogether 1230 papers have been found which deal with resections and reveal survival information. Only 621 of these report 5-year survivors. Reservation about surgery was first expressed in 1964 and five-year survival of nonresected survivors is well documented. Results. The survival percentage depends not only on the number of survivors but also on the subset from which it is calculated. Since the 1980s the papers have mainly reported the number of resections and survival as actuarial percentages, with or without the actual number of survivors being reported. The actuarial percentage is on average 2.75 higher. Detailed information on the original group (TN), number of resections, and actual number of survivors is reported in only 10.6% of the papers. Repetition occurs when the patients from a certain year are reported several times from the same institution or include survivors from many institutions or countries. Each 5-year survivor may be reported several times. Conclusion. Assuming a 10% resection rate and correcting for repetitions and the life table percentage the overall actual survival rate is hardly more than 0.3%.
Collapse
|
5
|
Multi-institutional pooled analysis on adjuvant chemoradiation in pancreatic cancer. Int J Radiat Oncol Biol Phys 2014; 90:911-7. [PMID: 25220717 DOI: 10.1016/j.ijrobp.2014.07.024] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 07/03/2014] [Accepted: 07/16/2014] [Indexed: 12/29/2022]
Abstract
PURPOSE To determine the impact of chemoradiation therapy (CRT) on overall survival (OS) after resection of pancreatic adenocarcinoma. METHODS AND MATERIALS A multicenter retrospective review of 955 consecutive patients who underwent complete resection with macroscopically negative margins (R0-1) for invasive carcinoma (T1-4; N0-1; M0) of the pancreas was performed. Exclusion criteria included metastatic or unresectable disease at surgery, macroscopic residual disease (R2), treatment with intraoperative radiation therapy (IORT), and a histological diagnosis of no ductal carcinoma, or postoperative death (within 60 days of surgery). In all, 623 patients received postoperative radiation therapy (RT), 575 patients received concurrent chemotherapy (CT), and 462 patients received adjuvant CT. RESULTS Median follow-up was 21.0 months. Median OS after adjuvant CRT was 39.9 versus 24.8 months after no adjuvant CRT (P<.001) and 27.8 months after CT alone (P<.001). Five-year OS was 41.2% versus 24.8% with and without postoperative CRT, respectively. The positive impact of CRT was confirmed by multivariate analysis (hazard ratio [HR] = 0.72; confidence interval [CI], 0.60-0.87; P=.001). Adverse prognostic factors identified by multivariate analysis included the following: R1 resection (HR = 1.17; CI = 1.07-1.28; P<.001), higher pT stage (HR = 1.23; CI = 1.11-1.37; P<.001), positive lymph nodes (HR = 1.27; CI = 1.15-1.41; P<.001), and tumor diameter >20 mm (HR = 1.14; CI = 1.05-1.23; P=.002). Multivariate analysis also showed a better prognosis in patients treated in centers with >10 pancreatic resections per year (HR = 0.87; CI = 0.78-0.97; P=.014) CONCLUSION: This study represents the largest comparative study on adjuvant therapy in patients after resection of carcinoma of the pancreas. Overall survival was better in patients who received adjuvant CRT.
Collapse
|
6
|
Chuong MD, Boggs DH, Patel KN, Regine WF. Adjuvant chemoradiation for pancreatic cancer: what does the evidence tell us? J Gastrointest Oncol 2014; 5:166-77. [PMID: 24982765 DOI: 10.3978/j.issn.2078-6891.2014.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 05/08/2014] [Indexed: 12/12/2022] Open
Abstract
The role of adjuvant chemoradiation (CRT) for pancreas cancer remains unclear. A handful of randomized trials conducted decades of ago ignited a debate that continues today about whether CRT improves survival after surgery. The many flaws in these trials are well described in the literature, which include the use of antiquated radiation delivery techniques and suboptimal doses. Recent prospective randomized data is lacking, and we eagerly await the results the ongoing Radiation Therapy Oncology Group (RTOG) 0848 trial that is evaluating the utility of high quality adjuvant CRT in resected pancreas cancer patients. Until the results of RTOG 0848 are available we should look to other studies from the modern era to guide adjuvant treatment recommendations. Here we review the current state of the art for adjuvant pancreas CRT with respect to patient selection, radiation techniques, radiation dose, and integration with novel systemic agents.
Collapse
Affiliation(s)
- Michael D Chuong
- Department of Radiation Oncology, University of Maryland Medical Systems, Baltimore, MD 21201, USA
| | - Drexell H Boggs
- Department of Radiation Oncology, University of Maryland Medical Systems, Baltimore, MD 21201, USA
| | - Kruti N Patel
- Department of Radiation Oncology, University of Maryland Medical Systems, Baltimore, MD 21201, USA
| | - William F Regine
- Department of Radiation Oncology, University of Maryland Medical Systems, Baltimore, MD 21201, USA
| |
Collapse
|
7
|
Caravatta L, Sallustio G, Pacelli F, Padula GDA, Deodato F, Macchia G, Massaccesi M, Picardi V, Cilla S, Marinelli A, Cellini N, Valentini V, Morganti AG. Clinical target volume delineation including elective nodal irradiation in preoperative and definitive radiotherapy of pancreatic cancer. Radiat Oncol 2012; 7:86. [PMID: 22691275 PMCID: PMC3494529 DOI: 10.1186/1748-717x-7-86] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Accepted: 06/05/2012] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Radiotherapy (RT) is widely used in the treatment of pancreatic cancer. Currently, recommendation has been given for the delineation of the clinical target volume (CTV) in adjuvant RT. Based on recently reviewed pathologic data, the aim of this study is to propose criteria for the CTV definition and delineation including elective nodal irradiation (ENI) in the preoperative and definitive treatment of pancreatic cancer. METHODS The anatomical structures of interest, as well as the abdominal vasculature were identified on intravenous contrast-enhanced CT scans of two different patients with pancreatic cancer of the head and the body. To delineate the lymph node area, a margin of 10 mm was added to the arteries. RESULTS We proposed a set of guidelines for elective treatment of high-risk nodal areas and CTV delineation. Reference CT images were provided. CONCLUSIONS The proposed guidelines could be used for preoperative or definitive RT for carcinoma of the head and body of the pancreas. Further clinical investigations are needed to validate the defined CTVs.
Collapse
Affiliation(s)
- Luciana Caravatta
- Radiotherapy Unit, Department of Oncology, Fondazione di Ricerca e Cura “Giovanni Paolo II”, Università Cattolica del S. Cuore, Largo A. Gemelli 1, 86100, Campobasso, Italy
| | - Giuseppina Sallustio
- Radiology Unit, Fondazione di Ricerca e Cura “Giovanni Paolo II”, Università Cattolica del S. Cuore, Largo A. Gemelli 1, 86100, Campobasso, Italy
| | - Fabio Pacelli
- Surgery Unit, Department of Oncology, Fondazione di Ricerca e Cura “Giovanni Paolo II”, Università Cattolica del S. Cuore, Largo A. Gemelli 1, 86100, Campobasso, Italy
| | - Gilbert DA Padula
- Radiation Oncology Department, The Lacks Cancer Center Saint Mary’s Health Care, Grand Rapids, MI, USA
| | - Francesco Deodato
- Radiotherapy Unit, Department of Oncology, Fondazione di Ricerca e Cura “Giovanni Paolo II”, Università Cattolica del S. Cuore, Largo A. Gemelli 1, 86100, Campobasso, Italy
| | - Gabriella Macchia
- Radiotherapy Unit, Department of Oncology, Fondazione di Ricerca e Cura “Giovanni Paolo II”, Università Cattolica del S. Cuore, Largo A. Gemelli 1, 86100, Campobasso, Italy
| | - Mariangela Massaccesi
- Radiotherapy Unit, Department of Oncology, Fondazione di Ricerca e Cura “Giovanni Paolo II”, Università Cattolica del S. Cuore, Largo A. Gemelli 1, 86100, Campobasso, Italy
| | - Vincenzo Picardi
- Radiotherapy Unit, Department of Oncology, Fondazione di Ricerca e Cura “Giovanni Paolo II”, Università Cattolica del S. Cuore, Largo A. Gemelli 1, 86100, Campobasso, Italy
| | - Savino Cilla
- Physics Unit, Fondazione di Ricerca e Cura Giovanni Paolo II, Università Cattolica del S. Cuore, Campobasso, Italy
| | - Alfonso Marinelli
- Radiotherapy Unit, Department of Oncology, Fondazione di Ricerca e Cura “Giovanni Paolo II”, Università Cattolica del S. Cuore, Largo A. Gemelli 1, 86100, Campobasso, Italy
| | - Numa Cellini
- Radiotherapy Department, Università Cattolica del S. Cuore, Rome, Italy
| | | | - Alessio G Morganti
- Radiotherapy Unit, Department of Oncology, Fondazione di Ricerca e Cura “Giovanni Paolo II”, Università Cattolica del S. Cuore, Largo A. Gemelli 1, 86100, Campobasso, Italy
- Radiotherapy Department, Università Cattolica del S. Cuore, Rome, Italy
| |
Collapse
|
8
|
Brand RE, Nolen BM, Zeh HJ, Allen PJ, Eloubeidi MA, Goldberg M, Elton E, Arnoletti JP, Christein JD, Vickers SM, Langmead CJ, Landsittel DP, Whitcomb DC, Grizzle WE, Lokshin AE. Serum biomarker panels for the detection of pancreatic cancer. Clin Cancer Res 2011; 17:805-16. [PMID: 21325298 DOI: 10.1158/1078-0432.ccr-10-0248] [Citation(s) in RCA: 175] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE Serum-biomarker based screening for pancreatic cancer could greatly improve survival in appropriately targeted high-risk populations. EXPERIMENTAL DESIGN Eighty-three circulating proteins were analyzed in sera of patients diagnosed with pancreatic ductal adenocarcinoma (PDAC, n = 333), benign pancreatic conditions (n = 144), and healthy control individuals (n = 227). Samples from each group were split randomly into training and blinded validation sets prior to analysis. A Metropolis algorithm with Monte Carlo simulation (MMC) was used to identify discriminatory biomarker panels in the training set. Identified panels were evaluated in the validation set and in patients diagnosed with colon (n = 33), lung (n = 62), and breast (n = 108) cancers. RESULTS Several robust profiles of protein alterations were present in sera of PDAC patients compared to the Healthy and Benign groups. In the training set (n = 160 PDAC, 74 Benign, 107 Healthy), the panel of CA 19-9, ICAM-1, and OPG discriminated PDAC patients from Healthy controls with a sensitivity/specificity (SN/SP) of 88/90%, while the panel of CA 19-9, CEA, and TIMP-1 discriminated PDAC patients from Benign subjects with an SN/SP of 76/90%. In an independent validation set (n = 173 PDAC, 70 Benign, 120 Healthy), the panel of CA 19-9, ICAM-1 and OPG demonstrated an SN/SP of 78/94% while the panel of CA19-9, CEA, and TIMP-1 demonstrated an SN/SP of 71/89%. The CA19-9, ICAM-1, OPG panel is selective for PDAC and does not recognize breast (SP = 100%), lung (SP = 97%), or colon (SP = 97%) cancer. CONCLUSIONS The PDAC-specific biomarker panels identified in this investigation warrant additional clinical validation to determine their role in screening targeted high-risk populations.
Collapse
Affiliation(s)
- Randall E Brand
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Ulla-Rocha JL, Alvarez-Prechous A, Paz-Esquete J, Alvarez CA, Lopez-Clemente P, Dominguez-Comesaña E, Vazquez-Astray E. The Global Impact of Endoscopic Ultrasound (EUS) Regarding the Survival of a Pancreatic Adenocarcinoma in a Tertiary Hospital. J Gastrointest Cancer 2010; 41:165-72. [DOI: 10.1007/s12029-010-9136-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
|
10
|
Abstract
BACKGROUND Resections for pancreatic ductal adenocarcinoma have now been carried out systematically for over 70 years. However, opinions still differ as to the results. Some consider it unresectable, whereas others claim a high survival percentage and recommend resections. METHODS The literature on this surgery has been scrutinized from the onset, and 790 studies have been found that deal with resections and reveal survival information. RESULTS Review reveals that the percentage of survivals is exaggerated with life-table methods when there is censoring of the data. Duplication of reporting survivors is rampant. CONCLUSION After adjusting for calculations and duplications, the total number of 5-year survivors can hardly be more than 700-800.
Collapse
|
11
|
Downstaging of pancreatic carcinoma after neoadjuvant chemoradiation. Strahlenther Onkol 2009; 185:557-66. [PMID: 19756421 DOI: 10.1007/s00066-009-1977-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2008] [Accepted: 04/09/2009] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE Neoadjuvant chemoradiation could improve survival in patients with pancreatic cancer because of a higher rate of R0 resections, lower rate of nodal metastasis (ypN) and of local recurrence. This approach was tested in a cohort to estimate its effect on survival. PATIENTS AND METHODS Three-dimensional, conformal radiation to the primary tumor (55.8 Gy) and the lymphatics (50.4 Gy) was combined with chemotherapy. Resection was performed 6 weeks after completion of chemoradiation. RESULTS 38 of 120 patients with locally advanced cancer underwent tumor resection thereafter. Three patients (8%) had pathologic complete response. Median tumor-specific survival was 29 months and overall survival 25 months. Patients with clear margins (35/38; 89%) had a 3-year disease-specific survival rate of 51% versus 0% with positive margins (p = 0.008). Nodal disease rate decreased from 50% at pretherapeutic imaging to 32% at resection. Patients with ypN0 status (n = 26/38) had a 3-year tumor-specific survival rate of 50% compared to 31% in patients with ypN1 status. At multivariate analysis, resection status and nodal spread significantly predicted tumor-specific survival. Chemoradiation was generally well tolerated. CONCLUSION The current results support randomized testing of neoadjuvant chemoradiation to prove survival prolongation. Compared to the literature this approach seems to reduce the number of positive nodes.
Collapse
|
12
|
Wolff RA, Varadhachary GR, Evans DB. Adjuvant therapy for adenocarcinoma of the pancreas: analysis of reported trials and recommendations for future progress. Ann Surg Oncol 2008; 15:2773-86. [PMID: 18612703 DOI: 10.1245/s10434-008-0002-3] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2008] [Revised: 05/14/2008] [Accepted: 05/15/2008] [Indexed: 12/18/2022]
Abstract
The delivery of postoperative combined modality adjuvant therapy for completely resected pancreatic cancer was initially shown to be beneficial on the basis of a prospective, randomized trial published in 1985. Since then, oncologists have debated whether chemotherapy, chemoradiation, or both is optimal adjuvant therapy after pancreatectomy for ductal adenocarcinoma of the pancreas; no global consensus has emerged. Unfortunately, despite the completion of a number of subsequent randomized trials of adjuvant therapy since 1985, no further improvements in overall survival have materialized. This lack of progress is not simply the result of ineffective systemic therapies, but in part the result of poor trial design and calls for a more disciplined approach to the selection of patients for surgery, pathologic assessment of surgical resection margins, and postoperative (pretreatment) imaging. This is the only way to ensure that patients who receive adjuvant therapy are actually receiving therapy for radiographically occult possible microscopic disease, rather than therapy for incompletely resected locally advanced disease or early postoperative metastases. A critical analysis of completed adjuvant trials will be provided and a framework for the conduct of future trials of adjuvant therapy proposed.
Collapse
Affiliation(s)
- Robert A Wolff
- Department of Gastrointestinal Medical Oncology, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd., Unit 426, Houston, TX, 77030, USA.
| | | | | |
Collapse
|
13
|
Brunner TB, Grabenbauer GG, Meyer T, Golcher H, Sauer R, Hohenberger W. Primary resection versus neoadjuvant chemoradiation followed by resection for locally resectable or potentially resectable pancreatic carcinoma without distant metastasis. A multi-centre prospectively randomised phase II-study of the Interdisciplinary Working Group Gastrointestinal Tumours (AIO, ARO, and CAO). BMC Cancer 2007; 7:41. [PMID: 17338829 PMCID: PMC1821337 DOI: 10.1186/1471-2407-7-41] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2006] [Accepted: 03/06/2007] [Indexed: 12/13/2022] Open
Abstract
Background The disappointing results of surgical therapy alone of ductal pancreatic cancer can only be improved using multimodal approaches. In contrast to adjuvant therapy, neoadjuvant chemoradiation is able to facilitate resectability with free margins and to lower lymphatic spread. Another advantage is better tolerability which consecutively allows applying multimodal treatment in a higher number of patients. Furthermore, the synopsis of the overall survival results of neoadjuvant trials suggests a higher rate compared to adjuvant trials. Methods/Design As there are no prospectively randomised studies for neoadjuvant therapy, the Interdisciplinary Study Group of Gastrointestinal Tumours of the German Cancer Aid has started such a trial. The study investigates the effect of neoadjuvant chemoradiation in locally resectable or probably resectable cancer of the pancreatic head without distant metastasis on median overall survival time compared to primary surgery. Adjuvant chemotherapy is integrated into both arms. Discussion The protocol of the study is presented in condensed form after an introducing survey on adjuvant and neoadjuvant therapy in pancreatic cancer.
Collapse
Affiliation(s)
- Thomas B Brunner
- Department of Radiation Oncology of the University at Erlangen-Nuremberg, Erlangen, Germany
| | - Gerhard G Grabenbauer
- Department of Radiation Oncology of the University at Erlangen-Nuremberg, Erlangen, Germany
| | - Thomas Meyer
- Department of Surgery of the University at Erlangen-Nuremberg, Erlangen, Germany
| | - Henriette Golcher
- Department of Surgery of the University at Erlangen-Nuremberg, Erlangen, Germany
| | - Rolf Sauer
- Department of Radiation Oncology of the University at Erlangen-Nuremberg, Erlangen, Germany
| | - Werner Hohenberger
- Department of Surgery of the University at Erlangen-Nuremberg, Erlangen, Germany
| |
Collapse
|
14
|
Shibata K, Matsumoto T, Yada K, Sasaki A, Ohta M, Kitano S. Factors predicting recurrence after resection of pancreatic ductal carcinoma. Pancreas 2005; 31:69-73. [PMID: 15968250 DOI: 10.1097/01.mpa.0000166998.04266.88] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Pancreatic ductal carcinoma frequently recurs postoperatively, and we analyzed clinicopathological features of patients treated by surgical resection to find predictors of postoperative recurrence. METHODS A retrospective cohort study was performed that included 69 patients between 1985 and 2003. Clinicopathologic factors were evaluated for tumor recurrences by univariate and multivariate analyses. RESULTS Mean survival time and actuarial 5-year disease-specific survival were significantly lower in cases of hepatic metastasis (13 months, 0%) and in cases of peritoneal carcinomatosis (15 months, 6.8%) than in cases of local retroperitoneal recurrence (30 months, 21%). Univariate and logistic regression analyses showed undifferentiated adenocarcinoma to be independently associated with hepatic metastasis (odds ratio, 7.4; 95% confidence interval, 1.5-37.0) and invasion of the portal vein to be independently associated with peritoneal carcinomatosis (odds ratio, 4.0; 95% confidence interval, 1.2-12.8). Multivariate analysis showed undifferentiated adenocarcinoma, invasion of the anterior capsule, and invasion of the portal vein to be independent prognostic factors. CONCLUSION Undifferentiated adenocarcinoma and invasion of the portal vein are predictors of poor outcome and are related to hepatic metastasis and peritoneal carcinomatosis, respectively. Postoperative adjuvant chemotherapy, including intra-arterial chemotherapy, should be selected according to prediction of the patterns of recurrence.
Collapse
Affiliation(s)
- Kohei Shibata
- Department of Surgery I, Oita University Faculty of Medicine, Oita, Japan.
| | | | | | | | | | | |
Collapse
|
15
|
Raut CP, Evans DB, Crane CH, Pisters PWT, Wolff RA. Neoadjuvant therapy for resectable pancreatic cancer. Surg Oncol Clin N Am 2004; 13:639-61, ix. [PMID: 15350939 DOI: 10.1016/j.soc.2004.06.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The length and quality of life of patients with localized pancreatic cancer will be maximized by accurate preoperative assessment of resectability, a standardized technique of tumor resection, and the routine use of protocol-based adjuvant or neoadjuvant therapy. Continued efforts to enroll patients with localized and advanced pancreatic cancer into well-designed clinical trials should remain a high priority for oncologists across all disciplines. At present, preoperative therapy remains investigational but has a sound clinical basis and remains a reasonable alternative to up front surgery. Future clinical trials for resectable pancreatic cancer will lead to progress only if the principles of multidisciplinary cancer care and quality assurance are incorporated into their design and conduct.
Collapse
Affiliation(s)
- Chandrajit P Raut
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77030, USA
| | | | | | | | | |
Collapse
|
16
|
van IJken MGA, van Etten B, Guetens G, ten Hagen TLM, Jeekel J, de Bruijn EA, Eggermont AMM, van Eijck CHJ. Balloon catheter hypoxic abdominal perfusion with Mitomycin C and Melphalan for locally advanced pancreatic cancer: a phase I-II trial. Eur J Surg Oncol 2004; 30:671-80. [PMID: 15256243 DOI: 10.1016/j.ejso.2004.03.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2004] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Developments in balloon catheter methodology have made hypoxic abdominal perfusion (HAP) with anti-tumour agents possible with only minimal invasive surgery. The initial reports on this modality and celiac axis stop-flow infusion for treatment of pancreatic cancer were very promising in terms of tumour response, median survival and pain reduction. Recent reports, however, have not been able to confirm these results and some have disputed the efficacy of these currently still applied treatment modalities. METHODS Twenty-one patients with advanced pancreatic carcinoma were included in a phase I-II trial of HAP with MMC and Melphalan followed by celiac axis infusion (CAI) with the same agents six weeks later. Tumour response was assessed by abdominal-CT and by determining tumour markers. Effect on pain reduction was assessed by evaluation of pain registration forms. RESULTS HAP resulted in augmented regional drug concentrations. One patient died after CAI due to acute mesenterial ischaemia. One agent-toxicity related death was observed in the phase-I study. Significant hematological toxicity was observed after HAP and CAI at MTD. No patients were considered resectable after treatment. Median survival after HAP was 6 months (range 1-29). Pain reduction was experienced by only 5/18 patients and was short-lived. CONCLUSION In contrast to earlier reports HAP and CAI with MMC and Melphalan did not demonstrate any benefit in terms of tumour response, median survival and pain reduction, compared to less invasive treatment options. As this treatment was associated with significant toxic side-effects and even one procedure related death, we do not consider this a therapeutic option in patients with advanced pancreatic cancer.
Collapse
Affiliation(s)
- M G A van IJken
- Department of Experimental Surgical Oncology, Erasmus Medical Center Rotterdam, Daniel den Hoed Cancer Centre, Groene Hilledijk 301, Rotterdam 3075 EA, The Netherlands
| | | | | | | | | | | | | | | |
Collapse
|
17
|
Lyshchik A, Higashi T, Nakamoto Y, Fujimoto K, Doi R, Imamura M, Saga T. Dual-phase 18F-fluoro-2-deoxy-D-glucose positron emission tomography as a prognostic parameter in patients with pancreatic cancer. Eur J Nucl Med Mol Imaging 2004; 32:389-97. [PMID: 15372209 DOI: 10.1007/s00259-004-1656-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2004] [Accepted: 07/22/2004] [Indexed: 12/14/2022]
Abstract
PURPOSE Recently, dual-phase 18F-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) was shown to be useful in the differentiation between malignant and benign pancreatic lesions. The aim of this prospective study was to evaluate the value of dual-phase FDG-PET as a prognostic parameter in patients with pancreatic cancer. METHODS Sixty-five consecutive patients with pancreatic cancer underwent dual-phase FDG-PET. Standardised uptake values at 1 h (SUV1) and 2 h (SUV2) following the injection of FDG were determined, and the retention index (RI) was calculated by dividing the difference between SUV2 and SUV1 by SUV1. The prognostic value of SUV1, SUV2 and RI was analysed, along with the various clinical and biochemical parameters. RESULTS Multivariate analysis showed that only three factors had an independent association with longer patient survival: female gender (p<0.01), TNM stage I-III (p<0.05) and RI>10% (p<0.01). Neither SUV1 nor SUV2 showed any prognostic significance. Combination of tumour stage and RI allowed more accurate prognostic evaluation. Patients at stage I-III with RI>10% survived longer than did patients at the same stage with RI<10% (15.3 vs 11.5 months, p<0.01). Patients at stage IV with RI>10% had an intermediate prognosis, with a median survival of 9.5 months; patients at stage IV with RI<10% showed the worst prognosis, with a median survival of 4.9 months (p<0.05). CONCLUSION RI calculated with dual-phase FDG-PET can be used not only as a tool for initial diagnosis and staging of pancreatic cancer but also as a strong independent prognostic parameter that can allow accurate identification of those patients who will benefit from intensive anticancer treatment at different stages of the disease.
Collapse
Affiliation(s)
- Andrej Lyshchik
- Department of Nuclear Medicine and Diagnostic Imaging, Kyoto University Graduate School of Medicine, 606-8507 Kyoto, Japan
| | | | | | | | | | | | | |
Collapse
|
18
|
Abstract
Eight cases of feline pancreatic adenocarcinoma and two cases of pancreatic adenoma were reviewed. The adenomas were incidental findings. Most cats with adenocarcinomas had anorexia (75%) and vomiting (63%), while 38% had abdominal pain, a palpable abdominal mass, and/or jaundice. Diagnostic abnormalities included leukocytosis, hyperglycemia, increased alanine aminotransferase activity, poor serosal detail on abdominal radiography, and an abdominal mass effect on ultrasonography. The majority of cats with carcinomas had metastases (mostly to liver, lung, and small intestine), and all were euthanized or died within 7 days of diagnosis. Clinically, feline pancreatic carcinoma may be difficult to distinguish from feline pancreatitis.
Collapse
Affiliation(s)
- Rebecca L Seaman
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Tennessee, Knoxville, Tennessee 37996, USA
| |
Collapse
|