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Seufferlein T, Mayerle J, Boeck 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 Exokrines Pankreaskarzinom – Version 3.1. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:e874-e995. [PMID: 39389103 DOI: 10.1055/a-2338-3533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/12/2024]
Affiliation(s)
| | | | | | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Gastroenterologie und Endokrinologie Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik und Poliklinik für Allgemein-, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg-Eppendorf, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Medizinische Klinik und Poliklinik II Onkologie und Hämatologie, Universitätsklinikum Hamburg-Eppendorf, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
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2
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Hatori M, Tsuji D, Suzuki K, Yokokawa T, Kawakami K, Moriyama R, Osada-Tsuchiya M, Otake A, Nakao M, Yano T, Arakawa Y, Matsuo K, Ohashi Y, Sakata Y, Kogure Y, Tamaki S, Wada A, Taki Y, Sasahira N, Ishii H, Yamaguchi M, Itoh K. Pharmacogenomic study of gemcitabine efficacy in patients with metastatic pancreatic cancer: A multicenter, prospective, observational cohort study (GENESECT study). Cancer 2024; 130:2988-2999. [PMID: 38682652 DOI: 10.1002/cncr.35343] [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: 02/13/2024] [Revised: 03/23/2024] [Accepted: 04/01/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND Genetic polymorphisms of molecules are known to cause individual differences in the therapeutic efficacy of anticancer drugs. However, to date, germline mutations (but not somatic mutations) for anticancer drugs have not been adequately studied. The objective of this study was to investigate the association between germline polymorphisms of gemcitabine metabolic and transporter genes with carbohydrate antigen 19-9 (CA 19-9) response (decrease ≥50% from the pretreatment level at 8 weeks) and overall survival (OS) in patients with metastatic pancreatic cancer who receive gemcitabine-based chemotherapy. METHODS This multicenter, prospective, observational study enrolled patients with metastatic pancreatic cancer patients who were receiving gemcitabine monotherapy or gemcitabine plus nanoparticle albumin-bound paclitaxel combination chemotherapy. Thirteen polymorphisms that may be involved in gemcitabine responsiveness were genotyped, and univariate and multivariate logistic regression analyses were used to determine the association of these genotypes with CA 19-9 response and OS. The significance level was set at 5%. RESULTS In total, 180 patients from 11 hospitals in Japan were registered, and 159 patients whose CA 19-9 response could be assessed were included in the final analysis. Patients who had a CA 19-9 response had significantly longer OS (372 vs. 241 days; p = .007). RRM1 2464A>G and RRM2 175T>G polymorphisms suggested a weak association with CA 19-9 response and OS, but it was not statistically significant. COX-2 -765G>C polymorphism did not significantly correlate with CA 19-9 response but was significantly associated with OS (hazard ratio, 2.031; p = .019). CONCLUSIONS Genetic polymorphisms from the pharmacokinetics of gemcitabine did not indicate a significant association with efficacy, but COX-2 polymorphisms involved in tumor cell proliferation might affect OS.
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Affiliation(s)
- Masahiro Hatori
- Department of Pharmacy, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
- Department of Clinical Pharmacology and Genetics, School of Pharmaceutical Sciences, University of Shizuoka, Shizuoka, Japan
| | - Daiki Tsuji
- Department of Clinical Pharmacology and Genetics, School of Pharmaceutical Sciences, University of Shizuoka, Shizuoka, Japan
| | - Kenichi Suzuki
- Department of Clinical Pharmacology, School of Pharmacy Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
| | - Takashi Yokokawa
- Department of Pharmacy, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Kazuyoshi Kawakami
- Department of Pharmacy, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Ryo Moriyama
- Department of Clinical Pharmacology and Genetics, School of Pharmaceutical Sciences, University of Shizuoka, Shizuoka, Japan
| | - Marika Osada-Tsuchiya
- Department of Clinical Pharmacology and Genetics, School of Pharmaceutical Sciences, University of Shizuoka, Shizuoka, Japan
| | - Aki Otake
- Department of Clinical Pharmacology and Genetics, School of Pharmaceutical Sciences, University of Shizuoka, Shizuoka, Japan
| | - Masahiko Nakao
- Department of Pharmacy and Clinical Research Center, Osaka City General Hospital, Osaka, Japan
| | - Takuya Yano
- Department of Pharmacy, Sumitomo Besshi Hospital, Niihama, Japan
| | - Yuichiro Arakawa
- Department of Pharmacy, Tochigi Cancer Center, Utsunomiya, Japan
| | - Keisuke Matsuo
- Department of Pharmacy, Beppu Medical Center, Beppu, Japan
| | - Yasukata Ohashi
- Department of Pharmacy, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yasuhiko Sakata
- Department of Pharmacy, Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Yuki Kogure
- Department of Pharmacy, National Center for Higashi-Hiroshima Medical Center, Higashi-Hiroshima, Japan
| | - Shinya Tamaki
- Department of Pharmacy, KKR Sapporo Medical Center, Sapporo, Japan
| | - Atsushi Wada
- Department of Pharmacy, Kobe Minimally Invasive Cancer Center, Kobe, Japan
| | - Yusuke Taki
- Department of Pharmacy, Kikugawa General Hospital, Kikugawa, Japan
| | - Naoki Sasahira
- Department of Gastroenterology, Cancer Institute Hospital, Tokyo, Japan
| | - Hiroshi Ishii
- Division of Gastroenterology, Chiba Cancer Center, Tokyo, Japan
| | - Masakazu Yamaguchi
- Department of Pharmacy, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Kunihiko Itoh
- Department of Clinical Pharmacology and Genetics, School of Pharmaceutical Sciences, University of Shizuoka, Shizuoka, Japan
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3
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Okano N, Kawai M, Ueno M, Yu X, Inoue Y, Takahashi S, Wang W, Takahashi H, Okamura Y, Morinaga S, Matsumoto I, Shimizu Y, Yoshida K, Yamamoto T, Ohtsuka M, Inokawa Y, Nara S, Tamura J, Shinoda S, Yamamoto K, Yamaue H, Furuse J. Outcomes of patients with initially unresectable pancreatic cancer who underwent conversion surgery after FOLFIRINOX or gemcitabine plus nab-paclitaxel chemotherapy: A multicenter retrospective cohort study (PC-CURE-1). JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2024. [PMID: 39150050 DOI: 10.1002/jhbp.12066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
BACKGROUND The efficacy and safety of conversion surgery (CS) after FOLFIRINOX or gemcitabine plus nab-paclitaxel (GnP) chemotherapy in patients with initially unresectable pancreatic cancer (PC) remains unclear. METHODS This multicenter retrospective cohort study enrolled patients, between 2014 and 2018, with initially locally advanced or metastatic PC who were considered candidates for CS following FOLFIRINOX or GnP chemotherapy. They were classified into surgery (207 patients [194 resection and 13 exploratory laparotomy only]) and continued chemotherapy (10 patients, control) groups. The primary endpoint was overall survival (OS) from the day of diagnosis of potentially curative resection on imaging studies, with an expected hazard ratio (HR) of 0.7. RESULTS OS in the surgery group was longer than that in the control group (HR, 0.47; 95% confidence interval [CI]: 0.24-0.93). The median OS was 34.4 (95% CI: 27.9-43.4) and 19.8 (95% CI: 14.9-31.1) months in the surgery and control groups, respectively. The Clavien-Dindo grade ≥ IIIa postoperative complication and in-hospital mortality rates were 19.6% and 0.5%, respectively. Multivariate analysis revealed that preoperative chemotherapy duration was not associated with OS. CONCLUSIONS CS, following a favorable response to FOLFIRINOX or GnP chemotherapy, improved initially unresectable PC prognosis (specifically, OS), regardless of the chemotherapy duration.
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Affiliation(s)
- Naohiro Okano
- Department of Medical Oncology, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Manabu Kawai
- Second Department of Surgery, Wakayama Medical University School of Medicine, Wakayama, Japan
| | - Makoto Ueno
- Department of Gastroenterology, Kanagawa Cancer Center, Yokohama, Japan
| | - Xianjun Yu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Yosuke Inoue
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Shinichiro Takahashi
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Wenquan Wang
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Hidenori Takahashi
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Yukiyasu Okamura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Soichiro Morinaga
- Department of Hepato-Biliary and Pancreatic Surgery, Kanagawa Cancer Center, Yokohama, Japan
| | - Ippei Matsumoto
- Department of Surgery, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Yasuhiro Shimizu
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Kazuhiro Yoshida
- Department of Surgical Oncology, Gifu University Graduate School of Medicine, Gifu, Japan
| | | | - Masayuki Ohtsuka
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yoshikuni Inokawa
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Satoshi Nara
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Jun Tamura
- Department of Biostatistics, Yokohama City University School of Medicine, Yokohama, Japan
| | - Satoru Shinoda
- Department of Biostatistics, Yokohama City University School of Medicine, Yokohama, Japan
| | - Kouji Yamamoto
- Department of Biostatistics, Yokohama City University School of Medicine, Yokohama, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, Wakayama Medical University School of Medicine, Wakayama, Japan
| | - Junji Furuse
- Department of Medical Oncology, Kyorin University Faculty of Medicine, Tokyo, Japan
- Department of Gastroenterology, Kanagawa Cancer Center, Yokohama, Japan
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Weisz Ejlsmark M, Bahij R, Schytte T, Rønn Hansen C, Bertelsen A, Mahmood F, Bau Mortensen M, Detlefsen S, Weber B, Bernchou U, Pfeiffer P. Adaptive MRI-guided stereotactic body radiation therapy for locally advanced pancreatic cancer - A phase II study. Radiother Oncol 2024; 197:110347. [PMID: 38815694 DOI: 10.1016/j.radonc.2024.110347] [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: 12/01/2023] [Revised: 05/17/2024] [Accepted: 05/22/2024] [Indexed: 06/01/2024]
Abstract
PURPOSE Stereotactic body radiotherapy (SBRT) has emerged as a promising new modality for locally advanced pancreatic cancer (LAPC). The current study evaluated the efficacy and toxicity of SBRT in patients with LAPC (NCT03648632). METHODS This prospective single institution phase II study recruited patients with histologically or cytologically proven adenocarcinoma of the pancreas after more than two months of combination chemotherapy with no sign of progressive disease. Patients were prescribed 50-60 Gy in 5-8 fractions. Patients were initially treated on a standard linac (n = 4). Since 2019, patients were treated using online magnetic resonance (MR) image-guidance on a 1.5 T MRI-linac, where the treatment plan was adapted to the anatomy of the day. The primary endpoint was resection rate. RESULTS Twenty-eight patients were enrolled between August 2018 and March 2022. All patients had non-resectable disease at time of diagnosis. Median follow-up from inclusion was 28.3 months (95 % CI 24.0-NR). Median progression-free and overall survival from inclusion were 7.8 months (95 % CI 5.0-14.8) and 16.5 months (95 % CI 10.7-22.6), respectively. Six patients experienced grade III treatment-related adverse events (jaundice, nausea, vomiting and/or constipation). One of the initial four patients receiving treatment on a standard linac experienced a grade IV perforation of the duodenum. Six patients (21 %) underwent resection. A further one patient was offered resection but declined. CONCLUSION This study demonstrates that SBRT in patients with LAPC was associated with promising overall survival and resection rates. Furthermore, SBRT was safe and well tolerated, with limited severe toxicities.
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Affiliation(s)
- Mathilde Weisz Ejlsmark
- Department of Oncology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark.
| | - Rana Bahij
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Tine Schytte
- Department of Oncology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Christian Rønn Hansen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, Odense, Denmark; Danish Centre of Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Anders Bertelsen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Faisal Mahmood
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Michael Bau Mortensen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Department of Surgery, Odense University Hospital, Odense, Denmark; Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark
| | - Sönke Detlefsen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Department of Pathology, Odense University Hospital, Odense, Denmark; Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark
| | - Britta Weber
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark; Danish Centre of Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Uffe Bernchou
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Per Pfeiffer
- Department of Oncology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark
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5
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Reni M, Giordano G, Audisio M, Orsi G, Macchini M, Gobba SM, Rapposelli I, Lucenti A, Luchena G, Faloppi L, Zustovich F, Ricci V, Cergnul M, Formica V, Procaccio L, Baccolini V, Briccolani A, Cascinu S, Peretti U. Exploring external validity of chemotherapy for pancreatic ductal adenocarcinoma in real life. Dig Liver Dis 2024:S1590-8658(24)00835-1. [PMID: 39003164 DOI: 10.1016/j.dld.2024.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 06/23/2024] [Accepted: 06/25/2024] [Indexed: 07/15/2024]
Abstract
INTRODUCTION Cisplatin, nab-paclitaxel, capecitabine, and gemcitabine (PAXG) regimen activity was assessed in a single institution phase II trial (PACT-19) on pancreatic ductal adenocarcinoma (PDAC). The PACT-31 study explored the external validity of PACT-19 results. MATERIALS AND METHODS Patients aged ≥18 and ≤75 years with KPS ≥70, and PDAC diagnosis receiving PAXG in the participating institutions were eligible and categorized as follows: A) PACT-19; B) PACT-31-HSR; C) PACT-31-non-HSR. With a sample of 175 patients, assuming a target 1-year overall survival of 60 % for metastatic and of 80 % for non-metastatic patients, the trial will be considered successful with the 1-year OS falling into the 95 % CI. RESULTS Data from 68 PACT-19 and 168 PACT-31 patients were retrieved. After 124 events, 1yOS was 52.5 % (95 %CI: 44.6-60.4 %) for metastatic and 80.5 % (95 %CI: 71.9-89.1 %) for non-metastatic patients. Survival overlapped between PACT-19 and PACT-31-HSR (median 17.6 and 17.4 months, p = 0.21) and was significantly shorter in PACT-31-non-HSR (median 11.3 months; p = 0.03). Differences of dose-intensity, use of maintenance therapy, and treatment after progression between PACT-31-HSR and non-HSR were evidenced. DISCUSSION PACT-19 results have external validity. The outcome difference between HSR and non-HSR centers endorses the need of creating a hub-and-spoke network aimed at sharing the expertise on rare-diseases.
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Affiliation(s)
- Michele Reni
- Department of Medical Oncology IRCCS Ospedale San Raffaele, Vita e Salute University, Via Olgettina 60, 20132 Milan, Italy.
| | - Guido Giordano
- Unit of Medical Oncology and Biomolecular Therapy, Policlinico Ospedali Riuniti di Foggia, Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto, 251, 71122 Foggia, Italy
| | - Marco Audisio
- Department of Oncology, University of Turin, AO Ordine Mauriziano, Medical Oncology Unit, ASL Torino 4, Ivrea, Turin, Italy
| | - Giulia Orsi
- Department of Medical Oncology IRCCS Ospedale San Raffaele, Vita e Salute University, Via Olgettina 60, 20132 Milan, Italy
| | - Marina Macchini
- Department of Medical Oncology IRCCS Ospedale San Raffaele, Vita e Salute University, Via Olgettina 60, 20132 Milan, Italy
| | - Stefania Maria Gobba
- Department of Medical Oncology, ASST-Settelaghi, Ospedale di Circolo, Viale Luigi Borri, 57, 21100 Varese, Italy
| | - Ilario Rapposelli
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Via Piero Maroncelli, 40, 47014 Meldola, (FC), Italy
| | - Antonio Lucenti
- U.O.C. Oncologia Medica Ospedale Maria Paternò Arezzo, 97100, Maria Paternò E Arezzo, Ragusa, Italy
| | - Giovanna Luchena
- U.O.C. Oncologia, Ospedale S. Anna ASST-LARIANA, Via Ravona, 1, 22020 San Fermo della Battaglia, Como, Italy
| | - Luca Faloppi
- Medical Oncology Unit, Azienda Sanitaria Territoriale di Macerata, Via Santa Lucia, 2, Macerata, Italy
| | - Fable Zustovich
- Department of Medical Oncology, AULSS 1 Dolomiti, Ospedale S.Martino, V.le Europa, 22, 32100 Belluno, Italy
| | - Vincenzo Ricci
- Medical Oncology Unit, Azienda Ospedaliera di Rilievo Nazionale 'San Pio', Via Dell'Angelo 1, Benevento, Italy
| | - Massimiliano Cergnul
- Ospedale Civile di Legnano, ASST OVEST MILANESE, Via Candiani, 2, 20025 Legnano, Italy
| | - Vincenzo Formica
- Medical Oncology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Viale Oxford, 81, 00133 Roma, Italy
| | - Letizia Procaccio
- Dept of Oncology Veneto Institute of Oncology IOV, IRCCS, Via Gattamelata, 64, 35128 Padova, Italy
| | - Valeria Baccolini
- Department of Medical Oncology IRCCS Ospedale San Raffaele, Vita e Salute University, Via Olgettina 60, 20132 Milan, Italy
| | - Assunta Briccolani
- Department of Medical Oncology IRCCS Ospedale San Raffaele, Vita e Salute University, Via Olgettina 60, 20132 Milan, Italy
| | - Stefano Cascinu
- Department of Medical Oncology IRCCS Ospedale San Raffaele, Vita e Salute University, Via Olgettina 60, 20132 Milan, Italy
| | - Umberto Peretti
- Department of Medical Oncology IRCCS Ospedale San Raffaele, Vita e Salute University, Via Olgettina 60, 20132 Milan, Italy
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6
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Seelen LWF, Doppenberg D, Stoop TF, Nagelhout A, Brada LJH, Bosscha K, Busch OR, Cirkel GA, den Dulk M, Daams F, van Dieren S, van Eijck CHJ, Festen S, Groot Koerkamp B, Haj Mohammad N, de Hingh IHJT, Lips DJ, Los M, de Meijer VE, Patijn GA, Polée MB, Stommel MWJ, Walma MS, de Wilde RF, Wilmink JW, Molenaar IQ, van Santvoort HC, Besselink MG. Minimum and Optimal CA19-9 Response After Two Months Induction Chemotherapy in Patients With Locally Advanced Pancreatic Cancer: A Nationwide Multicenter Study. Ann Surg 2024; 279:832-841. [PMID: 37477009 DOI: 10.1097/sla.0000000000006021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
OBJECTIVE This nationwide multicenter study aimed to define clinically relevant thresholds of relative serum CA19-9 response after 2 months of induction chemotherapy in patients with locally advanced pancreatic cancer (LAPC). BACKGROUND CA19-9 is seen as leading biomarker for response evaluation in patients with LAPC, but early clinically useful cut-offs are lacking. METHODS All consecutive patients with LAPC after 4 cycles (m)FOLFIRINOX or 2 cycles gemcitabine-nab-paclitaxel induction chemotherapy (±radiotherapy) with CA19-9 ≥5 U/mL at baseline were analyzed (2015-2019). The association of CA19-9 response with median OS (mOS) was evaluated for different CA19-9 cut-off points. Minimum and optimal CA19-9 response were established via log-rank test. Predictors for OS were analyzed using COX regression analysis. RESULTS Overall, 212 patients were included, of whom 42 (19.8%) underwent resection. Minimum CA19-9 response demonstrating a clinically significant median OS difference (12.7 vs. 19.6 months) was seen at ≥40% CA19-9 decrease. The optimal cutoff for CA19-9 response was ≥60% decrease (21.7 vs. 14.0 mo, P =0.021). Only for patients with elevated CA19-9 levels at baseline (n=184), CA19-9 decrease ≥60% [hazard ratio (HR)=0.59, 95% CI, 0.36-0.98, P =0.042] was independently associated with prolonged OS, as were SBRT (HR=0.42, 95% CI, 0.25-0.70; P =0.001), and resection (HR=0.25, 95% CI, 0.14-0.46, P <0.001), and duration of chemotherapy (HR=0.75, 95% CI, 0.69-0.82, P <0.001). CONCLUSIONS CA19-9 decrease of ≥60% following induction chemotherapy as optimal response cut-off in patients with LAPC is an independent predictor for OS when CA19-9 is increased at baseline. Furthermore, ≥40% is the minimum cut-off demonstrating survival benefit. These cut-offs may be used when discussing treatment strategies during early response evaluation.
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Affiliation(s)
- Leonard W F Seelen
- Department of Surgery, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, The Netherlands
| | - Deesje Doppenberg
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Thomas F Stoop
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Anne Nagelhout
- Department of Surgery, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, The Netherlands
| | - Lilly J H Brada
- Department of Surgery, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, The Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Olivier R Busch
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Geert A Cirkel
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, Meander Medical Center Amersfoort, University Medical Center, Utrecht, The Netherlands
| | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Germany
| | - Freek Daams
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Susan van Dieren
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Nadia Haj Mohammad
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, University Medical Center, Utrecht, The Netherlands
| | | | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Maartje Los
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center, Utrecht, The Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala Clinics, Zwolle, The Netherlands
| | - Marco B Polée
- Department of Medical Oncology, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marieke S Walma
- Department of Surgery, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, The Netherlands
| | - Roeland F de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Johanna W Wilmink
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Amsterdam UMC, University of Amsterdam, Department of Medical Oncology, Amsterdam, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, The Netherlands
| | - Marc G Besselink
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
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7
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Stoop TF, Seelen LWF, van 't Land FR, Lutchman KRD, van Dieren S, Lips DJ, van der Harst E, Kazemier G, Patijn GA, de Hingh IH, Wijsman JH, Erdmann JI, Festen S, Groot Koerkamp B, Mieog JSD, den Dulk M, Stommel MWJ, Busch OR, de Wilde RF, de Meijer VE, Te Riele W, Molenaar IQ, van Eijck CHJ, van Santvoort HC, Besselink MG. Nationwide Use and Outcome of Surgery for Locally Advanced Pancreatic Cancer Following Induction Chemotherapy. Ann Surg Oncol 2024; 31:2640-2653. [PMID: 38105377 DOI: 10.1245/s10434-023-14650-6] [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: 06/29/2023] [Accepted: 11/09/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Several international high-volume centers have reported good outcomes after resection of locally advanced pancreatic cancer (LAPC) following chemo(radio)therapy, but it is unclear how this translates to nationwide clinical practice and outcome. This study aims to assess the nationwide use and outcome of resection of LAPC following induction chemo(radio)therapy. PATIENTS AND METHODS A multicenter retrospective study including all patients who underwent resection for LAPC following chemo(radio)therapy in all 16 Dutch pancreatic surgery centers (2014-2020), registered in the mandatory Dutch Pancreatic Cancer Audit. LAPC is defined as arterial involvement > 90° and/or portomesenteric venous > 270° involvement or occlusion. RESULTS Overall, 142 patients underwent resection for LAPC, of whom 34.5% met the 2022 National Comprehensive Cancer Network criteria. FOLFIRINOX was the most commonly (93.7%) used chemotherapy [median 5 cycles (IQR 4-8)]. Venous and arterial resections were performed in 51.4% and 14.8% of patients. Most resections (73.9%) were performed in high-volume centers (i.e., ≥ 60 pancreatoduodenectomies/year). Overall median volume of LAPC resections/center was 4 (IQR 1-7). In-hospital/30-day major morbidity was 37.3% and 90-day mortality was 4.2%. Median OS from diagnosis was 26 months (95% CI 23-28) and 5-year OS 18%. Surgery in high-volume centers [HR = 0.542 (95% CI 0.318-0.923)], ypN1-2 [HR = 3.141 (95% CI 1.886-5.234)], and major morbidity [HR = 2.031 (95% CI 1.272-3.244)] were associated with OS. CONCLUSIONS Resection of LAPC following chemo(radio)therapy is infrequently performed in the Netherlands, albeit with acceptable morbidity, mortality, and OS. Given these findings, a structured nationwide approach involving international centers of excellence would be needed to improve selection of patients with LAPC for surgical resection following induction therapy.
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Affiliation(s)
- Thomas F Stoop
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Leonard W F Seelen
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht/St. Antonius Hospital Nieuwegein, Utrecht, Nieuwegein, The Netherlands
| | - Freek R van 't Land
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Kishan R D Lutchman
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Susan van Dieren
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | - Geert Kazemier
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Amsterdam UMC, Location Vrije University, Department of Surgery, Amsterdam, The Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala Clinics, Zwolle, The Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Jan H Wijsman
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | - Joris I Erdmann
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Aachen, Germany
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Olivier R Busch
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Roeland F de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Wouter Te Riele
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht/St. Antonius Hospital Nieuwegein, Utrecht, Nieuwegein, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht/St. Antonius Hospital Nieuwegein, Utrecht, Nieuwegein, The Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht/St. Antonius Hospital Nieuwegein, Utrecht, Nieuwegein, The Netherlands
| | - Marc G Besselink
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
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8
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Stoop TF, Theijse RT, Seelen LWF, Groot Koerkamp B, van Eijck CHJ, Wolfgang CL, van Tienhoven G, van Santvoort HC, Molenaar IQ, Wilmink JW, Del Chiaro M, Katz MHG, Hackert T, Besselink MG. Preoperative chemotherapy, radiotherapy and surgical decision-making in patients with borderline resectable and locally advanced pancreatic cancer. Nat Rev Gastroenterol Hepatol 2024; 21:101-124. [PMID: 38036745 DOI: 10.1038/s41575-023-00856-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2023] [Indexed: 12/02/2023]
Abstract
Surgical resection combined with systemic chemotherapy is the cornerstone of treatment for patients with localized pancreatic cancer. Upfront surgery is considered suboptimal in cases with extensive vascular involvement, which can be classified as either borderline resectable pancreatic cancer or locally advanced pancreatic cancer. In these patients, FOLFIRINOX or gemcitabine plus nab-paclitaxel chemotherapy is currently used as preoperative chemotherapy and is eventually combined with radiotherapy. Thus, more patients might reach 5-year overall survival. Patient selection for chemotherapy, radiotherapy and subsequent surgery is based on anatomical, biological and conditional parameters. Current guidelines and clinical practices vary considerably regarding preoperative chemotherapy and radiotherapy, response evaluation, and indications for surgery. In this Review, we provide an overview of the clinical evidence regarding disease staging, preoperative therapy, response evaluation and surgery in patients with borderline resectable pancreatic cancer or locally advanced pancreatic cancer. In addition, a clinical work-up is proposed based on the available evidence and guidelines. We identify knowledge gaps and outline a proposed research agenda.
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Affiliation(s)
- Thomas F Stoop
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, Netherlands
- Cancer Center Amsterdam, Amsterdam, Netherlands
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Rutger T Theijse
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, Netherlands
- Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Leonard W F Seelen
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus Medical Center, Rotterdam, Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus Medical Center, Rotterdam, Netherlands
| | - Christopher L Wolfgang
- Division of Surgical Oncology, Department of Surgery, New York University Medical Center, New York City, NY, USA
| | - Geertjan van Tienhoven
- Cancer Center Amsterdam, Amsterdam, Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Radiation Oncology, Amsterdam, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, Netherlands
| | - Johanna W Wilmink
- Cancer Center Amsterdam, Amsterdam, Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Medical Oncology, Amsterdam, Netherlands
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Marc G Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, Netherlands.
- Cancer Center Amsterdam, Amsterdam, Netherlands.
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9
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Watanabe Y, Tatsuguchi T, Date K, Shinkawa T, Kuga H, Tamiya S, Nishihara K, Nakano T. Conversion surgery for initially unresectable locally advanced pancreatic ductal adenocarcinoma after chemotherapy followed by carbon-ion radiotherapy: a case report. J Med Case Rep 2024; 18:13. [PMID: 38200536 PMCID: PMC10782725 DOI: 10.1186/s13256-023-04311-3] [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: 03/31/2023] [Accepted: 12/07/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Recent advances in chemotherapy and chemoradiotherapy have enabled conversion surgery (CS) to be performed for selected patients with initially unresectable locally advanced (LA) pancreatic ductal adenocarcinoma (PDAC). Many studies indicate CS might extend the survival of patients with initially unresectable LA PDAC. However, several clinical questions concerning CS remain, such as the optimal preoperative treatment. Carbon-ion radiotherapy (CIRT) is a unique radiotherapy that offers higher biological effectiveness than conventional radiotherapy. Here, we report a long-term survival case with initially unresectable LA PDAC who underwent CS after chemotherapy followed by CIRT. CASE PRESENTATION The patient was a 72-year-old Japanese woman with unresectable LA pancreatic head cancer with tumor contact to the superior mesenteric artery (SMA). She underwent four courses of chemotherapy (gemcitabine plus nanoparticle albumin-bound paclitaxel). However, the lesion did not shrink and tumor contact with the SMA did not improve after chemotherapy. Because the probability of achieving curative resection was judged to be low, she underwent radical dose CIRT, and chemotherapy was continued. She complained of vomiting 2 months after CIRT. Although imaging studies showed no tumor growth or metastasis, a duodenal obstruction which was speculated to be an adverse effect of CIRT was observed. She could not eat solid food and a trans-nasal feeding tube was inserted. Therapeutic intervention was required to enable enteral nutrition. We proposed several treatment options. She chose resection with the expectation of an anti-tumor effect of chemotherapy and CIRT rather than course observation with tube feeding or bypass surgery. Therefore, subtotal-stomach-preserving pancreatoduodenectomy with portal vein resection was performed as CS. Pathological examination of the resected specimen revealed an R0 resection with a histological response of Evans grade IIA. Postoperatively, she recovered uneventfully. Adjuvant chemotherapy with tegafur/gimeracil/oteracil (S1) was administrated. At the time of this report, 5 years have passed since the initial consultation and she has experienced no tumor recurrence. CONCLUSIONS The present case suggests that multidisciplinary treatment consisting of a combination of recent chemotherapy and CIRT may be beneficial for unresectable LA PDAC. However, further studies are required to assess the true efficacy of this treatment strategy.
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Affiliation(s)
- Yusuke Watanabe
- Department of Surgery, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-Ku, Kitakyushu, 802-0077, Japan.
- Department of Surgery, Hamanomachi Hospital, 3-3-1 Nagahama, Chuo-Ku, Fukuoka, 810-8539, Japan.
| | - Takaaki Tatsuguchi
- Department of Surgery, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-Ku, Kitakyushu, 802-0077, Japan
| | - Kenjiro Date
- Department of Surgery, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-Ku, Kitakyushu, 802-0077, Japan
| | - Tomohiko Shinkawa
- Department of Surgery, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-Ku, Kitakyushu, 802-0077, Japan
| | - Hirotaka Kuga
- Department of Surgery, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-Ku, Kitakyushu, 802-0077, Japan
| | - Sadafumi Tamiya
- Department of Pathology, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-Ku, Kitakyushu, 802-0077, Japan
| | - Kazuyoshi Nishihara
- Department of Surgery, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-Ku, Kitakyushu, 802-0077, Japan
| | - Toru Nakano
- Department of Surgery, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-Ku, Kitakyushu, 802-0077, Japan
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10
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Yang HK, Park MS, Han K, Eom G, Chung YE, Choi JY, Bang S, Kang CM, Seong J, Kim MJ. Risk Stratification of Pancreatic Ductal Adenocarcinoma Patients Undergoing Curative-Intent Surgery after Neoadjuvant Therapy. Cancer Res Treat 2024; 56:247-258. [PMID: 37605535 PMCID: PMC10789942 DOI: 10.4143/crt.2023.586] [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: 04/17/2023] [Accepted: 08/21/2023] [Indexed: 08/23/2023] Open
Abstract
PURPOSE Clinical prognostic criteria using preoperative factors were not developed for post-neoadjuvant therapy (NAT) surgery of pancreatic ductal adenocarcinoma (PDAC). We aimed to identify preoperative factors associated with overall survival (OS) in PDAC patients who underwent post-NAT curative-intent surgery and develop risk stratification criteria. MATERIALS AND METHODS Consecutive PDAC patients who underwent post-NAT curative-intent surgeries between 2007 and 2020 were retrospectively analyzed. Demographic, laboratory, surgical, and histopathologic variables were collected. Baseline, preoperative, and interval changes of computed tomography (CT) findings proposed by the Society of Abdominal Radiology and the American Pancreatic Association were analyzed. Cox proportional hazard analysis was used to select preoperative variables associated with OS. We developed risk stratification criteria composed of the significant preoperative variables, i.e., post-NAT response criteria. We compared the discrimination performance of post-NAT response criteria with that of post-NAT pathological (yp) American Joint Cancer Committee TNM staging system. RESULTS One hundred forty-five PDAC patients were included. Stable or increased tumor size on CT (hazard ratio [HR], 2.58; 95% confidence interval [CI], 1.58 to 4.21; p < 0.001) and elevated preoperative carbohydrate antigen 19-9 (CA19-9) level (HR, 1.98; 95% CI, 1.11 to 3.55; p=0.021) were independent factors of OS. The OS of the patient groups stratified by post-NAT response criteria which combined changes in tumor size and CA19-9 showed significant difference (p < 0.001). Such stratification was comparable to ypTNM staging in discrimination performance (difference of C-index, 0.068; 95% CI, -0.012 to 0.142). CONCLUSION "Any degree of decrease in tumor size on CT" and CA19-9 normalization or staying normal were independent favorable factors of OS. The combination of the two factors discriminated OS comparably to ypTNM staging.
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Affiliation(s)
- Hyun Kyung Yang
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Mi-Suk Park
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kyunghwa Han
- Department of Radiology, Research Institute of Radiological Sciences and Center for Clinical Imaging Data Science, Yonsei University College of Medicine, Seoul, Korea
| | - Geonsik Eom
- Department of Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Eun Chung
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jin-Young Choi
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seungmin Bang
- Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Chang Moo Kang
- Department of Surgery, Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jinsil Seong
- Department of Radiation Oncology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Myeong-Jin Kim
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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11
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Pacella G, Brunese MC, D’Imperio E, Rotondo M, Scacchi A, Carbone M, Guerra G. Pancreatic Ductal Adenocarcinoma: Update of CT-Based Radiomics Applications in the Pre-Surgical Prediction of the Risk of Post-Operative Fistula, Resectability Status and Prognosis. J Clin Med 2023; 12:7380. [PMID: 38068432 PMCID: PMC10707069 DOI: 10.3390/jcm12237380] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 09/10/2024] Open
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) is the seventh leading cause of cancer-related deaths worldwide. Surgical resection is the main driver to improving survival in resectable tumors, while neoadjuvant treatment based on chemotherapy (and radiotherapy) is the best option-treatment for a non-primally resectable disease. CT-based imaging has a central role in detecting, staging, and managing PDAC. As several authors have proposed radiomics for risk stratification in patients undergoing surgery for PADC, in this narrative review, we have explored the actual fields of interest of radiomics tools in PDAC built on pre-surgical imaging and clinical variables, to obtain more objective and reliable predictors. METHODS The PubMed database was searched for papers published in the English language no earlier than January 2018. RESULTS We found 301 studies, and 11 satisfied our research criteria. Of those included, four were on resectability status prediction, three on preoperative pancreatic fistula (POPF) prediction, and four on survival prediction. Most of the studies were retrospective. CONCLUSIONS It is possible to conclude that many performing models have been developed to get predictive information in pre-surgical evaluation. However, all the studies were retrospective, lacking further external validation in prospective and multicentric cohorts. Furthermore, the radiomics models and the expression of results should be standardized and automatized to be applicable in clinical practice.
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Affiliation(s)
- Giulia Pacella
- Department of Medicine and Health Science “V. Tiberio”, University of Molise, 86100 Campobasso, Italy; (G.P.)
| | - Maria Chiara Brunese
- Department of Medicine and Health Science “V. Tiberio”, University of Molise, 86100 Campobasso, Italy; (G.P.)
| | | | - Marco Rotondo
- Department of Medicine and Health Science “V. Tiberio”, University of Molise, 86100 Campobasso, Italy; (G.P.)
| | - Andrea Scacchi
- General Surgery Unit, University of Milano-Bicocca, 20126 Milan, Italy
| | - Mattia Carbone
- San Giovanni di Dio e Ruggi d’Aragona Hospital, 84131 Salerno, Italy;
| | - Germano Guerra
- Department of Medicine and Health Science “V. Tiberio”, University of Molise, 86100 Campobasso, Italy; (G.P.)
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12
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Farnes I, Kleive D, Verbeke CS, Aabakken L, Issa-Epe A, Småstuen MC, Fosby BV, Dueland S, Line PD, Labori KJ. Resection rates and intention-to-treat outcomes in borderline and locally advanced pancreatic cancer: real-world data from a population-based, prospective cohort study (NORPACT-2). BJS Open 2023; 7:zrad137. [PMID: 38155512 PMCID: PMC10755199 DOI: 10.1093/bjsopen/zrad137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 10/17/2023] [Accepted: 10/20/2023] [Indexed: 12/30/2023] Open
Abstract
BACKGROUND Systemic chemotherapy is the initial treatment strategy for borderline resectable and locally advanced pancreatic cancer to facilitate curative resection. The aim of this study was to investigate the resection rates and overall survival in patients with borderline resectable pancreatic cancer and locally advanced pancreatic cancer. METHODS Consecutive patients with borderline resectable pancreatic cancer/locally advanced pancreatic cancer discussed by Oslo University Hospital multidisciplinary team between 2018 and 2020, serving a population of 3.1 million within a geographically defined area in south-eastern Norway, were included in this prospective Norwegian Pancreatic Cancer Trial-2 study, according to intention-to-treat principles. The total number of patients with pancreatic cancer was sought from the Cancer Registry of Norway. RESULTS A total of 1178 patients were diagnosed with pancreatic cancer, of whom 618 were referred to Oslo University Hospital. After multidisciplinary team evaluation, 230 patients were considered to have borderline resectable pancreatic cancer/locally advanced pancreatic cancer. The final study group consisted of 188 patients (borderline resectable pancreatic cancer n = 96, locally advanced pancreatic cancer n = 92) who were fit to receive primary chemotherapy. Resection rates were 46.9% (45 of 96) for borderline resectable pancreatic cancer and 13% (12 of 92) for locally advanced pancreatic cancer (P <0.001). Median overall survival was 14.6 months (borderline resectable pancreatic cancer 16.4 months; locally advanced pancreatic cancer 13.7 months, (P = 0.2)). Adjusted for immortal time bias, median overall survival for patients undergoing resection versus only chemotherapy was 24.4 months versus 10.1 months (P <0.001) for borderline resectable pancreatic cancer and 28.4 months versus 12.6 months for locally advanced pancreatic cancer (P = 0.001). CONCLUSION Resection rates and survival in patients with borderline resectable pancreatic cancer and locally advanced pancreatic cancer treated at a high-volume centre in a universal healthcare system compare well with those treated at international expert centres.Registration number: NCT04423731 (http://www.clinicaltrials.gov).
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Affiliation(s)
- Ingvild Farnes
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Dyre Kleive
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Caroline S Verbeke
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Pathology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Lars Aabakken
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Section of Gastroenterology, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Aart Issa-Epe
- Department of Radiology, Oslo University Hospital, Oslo, Norway
| | | | - Bjarte V Fosby
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Svein Dueland
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Pål-Dag Line
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Knut J Labori
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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13
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Nakanishi K, Tanaka C, Kanda M, Miyata K, Furukawa K, Maeda O, Shimizu D, Sugita S, Kakushima N, Furune S, Kawashima H, Ando Y, Ebata T, Kodera Y. Low Expectancy of Conversion Surgery with R0 Resection in Patients with CEA > 5.0 ng/mL at the Initial RECIST Evaluation for Metastatic Gastric Cancer. Cancers (Basel) 2023; 15:5197. [PMID: 37958371 PMCID: PMC10650046 DOI: 10.3390/cancers15215197] [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: 10/17/2023] [Accepted: 10/27/2023] [Indexed: 11/15/2023] Open
Abstract
This retrospective study examined early the predictive factors for successful conversion surgery (CS) with R0 resection in patients with metastatic gastric cancer (MGC) who underwent systemic chemotherapy. This study included 204 patients diagnosed with metastatic gastric adenocarcinoma, who received chemotherapy between 2009 and 2019. Of these patients, 31 (15%) underwent CS with R0 resection. The incidence of CS with R0 resection was not affected by the volume of metastatic lesions or the presence of peritoneal metastasis. The overall survival time of the CS with R0 resection group was significantly longer than that of the non-CS group (hazard ratio, 0.12; 95% confidence interval, 0.07-0.23; p < 0.0001), with a 5 year overall survival rate of 50.2%. Multivariate analysis of 150 patients, excluding those with disease progression until the initial Response Evaluation Criteria in Solid Tumors (RECIST) evaluation, showed that carcinoembryonic antigen > 5.0 ng/mL at the initial RECIST evaluation was an independent, significant, and unfavorable predictor of CS with R0 resection (odds ratio, 0.21; p = 0.0108), whereas systemic chemotherapy with trastuzumab for HER2-positive cancer was a favorable factor (odds ratio, 4.20; p = 0.0119). Monitoring serum carcinoembryonic antigen levels during chemotherapy may be a useful predictor of the CS implementation in patients with MGC.
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Affiliation(s)
- Koki Nakanishi
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Chie Tanaka
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Mitsuro Kanda
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Kazushi Miyata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Kazuhiro Furukawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Osamu Maeda
- Department of Clinical Oncology and Chemotherapy, Nagoya University Hospital, Nagoya 466-8560, Japan
| | - Dai Shimizu
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Shizuki Sugita
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Naomi Kakushima
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Satoshi Furune
- Department of Clinical Oncology and Chemotherapy, Nagoya University Hospital, Nagoya 466-8560, Japan
| | - Hiroki Kawashima
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Yuichi Ando
- Department of Clinical Oncology and Chemotherapy, Nagoya University Hospital, Nagoya 466-8560, Japan
| | - Tomoki Ebata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Yasuhiro Kodera
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
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Oba A, Del Chiaro M, Fujii T, Okano K, Stoop TF, Wu YHA, Maekawa A, Yoshida Y, Hashimoto D, Sugawara T, Inoue Y, Tanabe M, Sho M, Sasaki T, Takahashi Y, Matsumoto I, Sasahira N, Nagakawa Y, Satoi S, Schulick RD, Yoon YS, He J, Jang JY, Wolfgang CL, Hackert T, Besselink MG, Takaori K, Takeyama Y. "Conversion surgery" for locally advanced pancreatic cancer: A position paper by the study group at the joint meeting of the International Association of Pancreatology (IAP) & Japan Pancreas Society (JPS) 2022. Pancreatology 2023; 23:712-720. [PMID: 37336669 DOI: 10.1016/j.pan.2023.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 04/10/2023] [Accepted: 06/06/2023] [Indexed: 06/21/2023]
Abstract
Locally advanced pancreatic cancer (LAPC), which progresses locally and surrounds major vessels, has historically been deemed unresectable. Surgery alone failed to provide curative resection and improve overall survival. With the advancements in treatment, reports have shown favorable results in LAPC after undergoing successful chemotherapy therapy or chemoradiation therapy followed by surgical resection, so-called "conversion surgery", at experienced high-volume centers. However, recognizing significant regional and institutional disparities in the management of LAPC, an international consensus meeting on conversion surgery for LAPC was held during the Joint Congress of the 26th Meeting of the International Association of Pancreatology (IAP) and the 53rd Annual Meeting of Japan Pancreas Society (JPS) in Kyoto in July 2022. During the meeting, presenters reported the current best multidisciplinary practices for LAPC, including preoperative modalities, best systemic treatment regimens and durations, procedures of conversion surgery with or without vascular resections, biomarkers, and genetic studies. It was unanimously agreed among the experts in this meeting that "cancer biology is surpassing locoregional anatomical resectability" in the era of effective multiagent treatment. The biology of pancreatic cancer has yet to be further elucidated, and we believe it is essential to improve the treatment outcomes of LAPC patients through continued efforts from each institution and more international collaboration. This article summarizes the agreement during the discussion amongst the experts in the meeting. We hope that this will serve as a foundation for future international collaboration and recommendations for future guidelines.
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Affiliation(s)
- Atsushi Oba
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan; Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA; Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA.
| | - Tsutomu Fujii
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, Japan
| | - Keiichi Okano
- Department of Gastroenterological Surgery, Kagawa University School of Medicine, Kagawa, Japan
| | - Thomas F Stoop
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Y H Andrew Wu
- Department Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aya Maekawa
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan; Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yuta Yoshida
- Department of Surgery, Kindai University, Osaka, Japan
| | | | - Toshitaka Sugawara
- Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA; Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yosuke Inoue
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Minoru Tanabe
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Takashi Sasaki
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Yu Takahashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | | | - Naoki Sasahira
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Sohei Satoi
- Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA; Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Richard D Schulick
- Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jin He
- Department Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | | | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany; Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Germany
| | - Marc G Besselink
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
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15
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Tanaka M, Heckler M, Mihaljevic AL, Ei S, Klaiber U, Heger U, Büchler MW, Hackert T. Induction Chemotherapy with FOLFIRINOX for Locally Advanced Pancreatic Cancer: A Simple Scoring System to Predict Effect and Prognosis. Ann Surg Oncol 2023; 30:2401-2408. [PMID: 36153440 PMCID: PMC10027766 DOI: 10.1245/s10434-022-12569-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 08/06/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Effective chemotherapy (CTx) protocols as induction treatment provide increasing opportunities for surgical resection of locally advanced pancreatic cancer (LAPC). Although improved survival after resection of LAPC with CTx has been reported for selected patients, reliable recommendations on the indication for conversion surgery after induction treatment are currently lacking. We investigated the factors predictive of prognosis in resected LAPC after FOLFIRINOX. METHODS Consecutive patients with LAPC undergoing curative resection after FOLFIRINOX between 2011 and 2018 were identified from a prospectively maintained database. Relevant clinical parameters and CT findings were examined. A scoring system was developed based on the ratio of hazard ratios for overall survival of all significant predictors. RESULTS A total of 62 patients with LAPC who underwent oncologic resection after FOLFIRINOX were analyzed. Tumor shrinkage, tumor density, and postchemotherapy CA19-9 serum levels were independently associated with overall survival (multivariate analysis: HR = 0.31, 0.17, and 0.18, respectively). One, two, and two points were allocated to these three factors in the proposed scoring system, respectively. The median overall survival of patients with a score from 0 to 2 was significantly shorter than that of patients with a score from 3 to 5 (22.1 months vs. 53.2 months, P < 0.001). CONCLUSIONS Tumor density is a novel predictive marker for the prognosis of patients with resected LAPC after FOLFIRINOX. A simple scoring model incorporating tumor density, the tumor shrinkage rate, and CA 19-9 levels identifies patients with a low score, who may be candidates for additional treatment.
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Affiliation(s)
- Masayuki Tanaka
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Department of Surgery, Keio University School of Medicine, Minato City, Japan
| | - Max Heckler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - André L Mihaljevic
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Department of General and Visceral Surgery, University Hospital Ulm, Ulm, Germany
| | - Shigenori Ei
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Ulla Klaiber
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Ulrike Heger
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.
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16
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Reni M, Orsi G. Lessons and open questions in borderline resectable pancreatic cancer. Lancet Gastroenterol Hepatol 2023; 8:101-102. [PMID: 36521503 DOI: 10.1016/s2468-1253(22)00393-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 11/17/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Michele Reni
- Department of Medical Oncology, Pancreas Translational and Clinical Research Center, Vita e Salute University, San Raffaele Scientific Institute, Milan, Italy.
| | - Giulia Orsi
- Department of Medical Oncology, Pancreas Translational and Clinical Research Center, Vita e Salute University, San Raffaele Scientific Institute, Milan, Italy
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17
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Reni M, Giommoni E, Bergamo F, Milella M, Cavanna L, Di Marco MC, Spada M, Cordio S, Aprile G, Cardellino GG, Maiello E, Bernardini I, Ghidini M, Bozzarelli S, Macchini M, Orsi G, De Simone I, Rulli E, Porcu L, Torri V, Pinto C. Guideline Application in Real world: multi-Institutional Based survey of Adjuvant and first-Line pancreatic Ductal adenocarcinoma treatment in Italy. Primary analysis of the GARIBALDI survey. ESMO Open 2023; 8:100777. [PMID: 36731325 PMCID: PMC10024128 DOI: 10.1016/j.esmoop.2022.100777] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/04/2022] [Accepted: 12/19/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Information about the adherence to scientific societies guidelines in the 'real-world' therapeutic management of oncological patients are lacking. This multicenter, prospective survey was aimed to improve the knowledge relative to 2017-2018 recommendations of the Italian Association of Medical Oncology (AIOM). PATIENTS AND METHODS Treatment-naive adult patients with pancreatic adenocarcinoma were enrolled. Group A received adjuvant therapy, group B received primary chemotherapy, and group C had metastatic disease. The results on patients accrued until 31 October 2019 with a mature follow-up were presented. RESULTS Since July 2017, 833 eligible patients of 923 (90%) were enrolled in 44 Italian centers. The median age was 69 years (range 36-89 years; 24% >75 years); 48% were female; 93% had Eastern Cooperative Oncology Group (ECOG) performance status (PS) score of 0 or 1; group A: 16%, group B: 30%; group C: 54%; 72% Nord, 13% Center, 15% South. In group A, guidelines adherence was 68% [95% confidence interval (CI) 59% to 76%]; 53% of patients received gemcitabine and 15% gemcitabine + capecitabine; median CA19.9 was 29 (range 0-7300; not reported 15%); median survival was 36.4 months (95% CI 27.5-47.3 months). In group B, guidelines adherence was 96% (95% CI 92% to 98%); 55% of patients received nab-paclitaxel + gemcitabine, 27% FOLFIRINOX, 12% gemcitabine, and 3% clinical trial; median CA19.9 was 337 (range 0-20220; not reported 9%); median survival was 18.1 months (95% CI 15.6-19.9 months). In group C, guidelines adherence was 96% (95% CI 94% to 98%); 71% of patients received nab-paclitaxel + gemcitabine, 16% gemcitabine, 8% FOLFIRINOX, and 4% clinical trial; liver and lung metastases were reported in 76% and 23% of patients, respectively; median CA19.9 value was 760 (range 0-1374500; not reported 9%); median survival was 10.0 months (95% CI 9.1-11.1 months). CONCLUSIONS The GARIBALDI survey shows a very high rate of adherence to guidelines and survival outcome in line with the literature. CA19.9 testing should be enhanced; nutritional and psychological counseling represent an unmet need. Enrollment to assess adherence to updated AIOM guidelines is ongoing.
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Affiliation(s)
- M Reni
- Department of Medical Oncology, Vita e Salute University, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - E Giommoni
- Medical Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - F Bergamo
- Unit of Medical Oncology 1, Department of Clinical and Experimental Oncology, Istituto Oncologico Veneto, IRCCS, Padua, Italy
| | - M Milella
- Oncology Verona, Policlinico Universitario G.B. Rossi Borgo Roma, Verona, Italy
| | - L Cavanna
- Oncology and Hematology Department, Oncology Unit, Piacenza General Hospital, Piacenza, Italy
| | | | - M Spada
- Unit of Oncology, San Raffaele G. Giglio Institute, Contrada Pietrapollastra - Pisciotto, Cefalù, Italy
| | - S Cordio
- ARNAS Garibaldi Nesima - Catania, Italy
| | - G Aprile
- San Bortolo General Hospital, ULSS8 Berica Est District - Vicenza, Italy
| | - G G Cardellino
- Department of Oncology, University & General Hospital, Udine Pz.le S. Maria della Misericordia 15, Udine, Italy
| | - E Maiello
- Medical Oncology, Hospital Casa Sollievo Della Sofferenza-San Giovanni Rotondo, Foggia, Italy
| | - I Bernardini
- Department of Oncology, Carpi and Mirandola Hospitals, Carpi e Mirandola, Italy
| | | | - S Bozzarelli
- Clinical Institute Humanitas - Rozzano (Milan), Milan, Italy
| | - M Macchini
- Department of Medical Oncology, Vita e Salute University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - G Orsi
- Department of Medical Oncology, Vita e Salute University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - I De Simone
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Er Rulli
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - L Porcu
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - V Torri
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - C Pinto
- AUSL-IRCCS Clinical Cancer Center of Reggio Emilia - Reggio Emilia, Italy
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18
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Kauffmann EF, Napoli N, Ginesini M, Gianfaldoni C, Asta F, Salamone A, Ripolli A, Di Dato A, Vistoli F, Amorese G, Boggi U. Tips and tricks for robotic pancreatoduodenectomy with superior mesenteric/portal vein resection and reconstruction. Surg Endosc 2023; 37:3233-3245. [PMID: 36624216 PMCID: PMC10082118 DOI: 10.1007/s00464-022-09860-0] [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: 08/28/2022] [Accepted: 12/27/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Open pancreatoduodenectomy with vein resection (OPD-VR) is now standard of care in patients who responded to neoadjuvant therapies. Feasibility of robotic pancreatoduodenectomy (RPD) with vein resection (RPD-VR) was shown, but no study provided a detailed description of the technical challenges associated with this formidable operation. Herein, we describe the trips and tricks for technically successful RPD-VR. METHODS The vascular techniques used in RPD-VR were borrowed from OPD-VR, as well as from our experience with robotic transplantation of both kidney and pancreas. Vein resection was classified into 4 types according to the international study group of pancreatic surgery. Each type of vein resection was described in detail and shown in a video. RESULTS Between October 2008 and November 2021, a total of 783 pancreatoduodenectomies were performed, including 233 OPDs-VR (29.7%). RPD was performed in 256 patients (32.6%), and RPDs-VR in 36 patients (4.5% of all pancreatoduodenectomies; 15.4% of all pancreatoduodenectomies with vein resection; 14.0% of all RPDs). In RPD-VR vein resections were: 4 type 1 (11.1%), 10 type 2 (27.8%), 12 type 3 (33.3%) and 10 type 4 (27.8%). Vascular patches used in type 2 resections were made of peritoneum (n = 8), greater saphenous vein (n = 1), and deceased donor aorta (n = 1). Interposition grafts used in type 4 resections were internal left jugular vein (n = 8), venous graft from deceased donor (n = 1) and spiral saphenous vein graft (n = 1). There was one conversion to open surgery (2.8%). Ninety-day mortality was 8.3%. There was one (2.8%) partial vein thrombosis, treated with heparin infusion. CONCLUSIONS We have reported 36 technically successful RPDs-VR. We hope that the tips and tricks provided herein can contribute to safer implementation of RPD-VR. Based on our experience, and according to data from the literature, we strongly advise that RPD-VR is performed by expert surgeons at high volume centers.
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Affiliation(s)
- Emanuele F Kauffmann
- Division of General and Transplant Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy.
| | - Niccolò Napoli
- Division of General and Transplant Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Michael Ginesini
- Division of General and Transplant Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Cesare Gianfaldoni
- Division of General and Transplant Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Fabio Asta
- Division of General and Transplant Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Alice Salamone
- Division of General and Transplant Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Allegra Ripolli
- Division of General and Transplant Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Armando Di Dato
- Division of General and Transplant Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Fabio Vistoli
- Division of General and Transplant Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Gabriella Amorese
- Division of Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
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19
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Huang JC, Pan B, Jiang T, Zhang XX, Lyu SC, Lang R. Effect of the preoperative prognostic nutritional index on the long-term prognosis in patients with borderline resectable pancreatic cancer after pancreaticoduodenectomy. Front Oncol 2023; 13:1098459. [PMID: 37197434 PMCID: PMC10183595 DOI: 10.3389/fonc.2023.1098459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 04/19/2023] [Indexed: 05/19/2023] Open
Abstract
Background The preoperative prognostic nutritional index (PNI) is an indicator of systemic immune-nutritional condition and is a well-known prognostic biomarker in cancer patients. This study aims to reflect the correlation between the preoperative PNI and prognosis in patients with borderline resectable pancreatic cancer (BRPC) after pancreaticoduodenectomy (PD). Methods Medical records of patients with BRPC after PD between Jan 2011 and Dec 2021 in our hospital were retrospectively analyzed. The preoperative PNI was calculated, and the receiver operating characteristic curve was obtained based on the preoperative PNI and the 1-year survival rate. Patients were divided into two groups (High-PNI and Low-PNI) following the best cut-off value of the preoperative PNI, and demographic and pathologic findings were compared between the two groups. Univariate and multivariate analysis were performed to identify risk factors in recurrence and long-term survival. Results The best cut-off value for the preoperative PNI was 44.6 (sensitivity: 62.46%; specificity: 83.33%; area under the curve: 0.724). Patients in the low-PNI group had significantly shorter recurrence-free survival (P=0.008) and overall survival (P=0.009). The preoperative PNI (P=0.009) and lymph node metastasis (P=0.04) were independent risk factors for tumor recurrence. The preoperative PNI (P=0.001), lymph node metastasis (P=0.04), neoadjuvant chemotherapy (P=0.04) were independent risk factors for long-term survival in patients. Conclusion The preoperative PNI, lymph node metastasis, neoadjuvant chemotherapy were independent risk factors for recurrence and long-term survival in patients with BRPC. The preoperative PNI might be an indicator that can predict BRPC patients' recurrence and survival. Patients with high-PNI would benefit from neoadjuvant chemotherapy.
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Affiliation(s)
| | | | | | | | | | - Ren Lang
- *Correspondence: Shao-Cheng Lyu, ; Ren Lang,
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20
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Maggino L, Malleo G, Crippa S, Belfiori G, Nobile S, Gasparini G, Lionetto G, Luchini C, Mattiolo P, Schiavo-Lena M, Doglioni C, Scarpa A, Bassi C, Falconi M, Salvia R. CA19.9 Response and Tumor Size Predict Recurrence Following Post-neoadjuvant Pancreatectomy in Initially Resectable and Borderline Resectable Pancreatic Ductal Adenocarcinoma. Ann Surg Oncol 2023; 30:207-219. [PMID: 36227391 PMCID: PMC9726670 DOI: 10.1245/s10434-022-12622-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 09/14/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Data on recurrence after post-neoadjuvant pancreatectomy are scant. This study investigated the incidence and pattern of recurrence in patients with initially resectable and borderline resectable pancreatic ductal adenocarcinoma who received post-neoadjuvant pancreatectomy. Furthermore, preoperative predictors of recurrence-free survival (RFS) and their interactions were determined. PATIENTS AND METHODS Patients undergoing post-neoadjuvant pancreatectomy at two academic facilities between 2013 and 2017 were analyzed using standard statistics. The possible interplay between preoperative parameters was scrutinized including interaction terms in multivariable Cox models. RESULTS Among 315 included patients, 152 (48.3%) were anatomically resectable. The median RFS was 15.7 months, with 1- and 3-year recurrence rates of 41.9% and 74.2%, respectively. Distant recurrence occurred in 83.3% of patients, with lung-only patterns exhibiting the most favorable prognostic outlook. Normal posttreatment CA19.9, ΔCA19.9 (both in patients with normal and elevated baseline levels), and posttreatment tumor size were associated with RFS. Critical thresholds for ΔCA19.9 and tumor size were set at 50% and 20 mm, respectively. Interaction between ΔCA19.9 and posttreatment CA19.9 suggested a significant risk reduction in patients with elevated values when ΔCA19.9 exceeded 50%. Moreover, posttreatment tumor size interacted with posttreatment CA19.9 and ΔCA19.9, suggesting an increased risk in the instance of elevated posttreatment CA19.9 values and a protective effect associated with CA19.9 response in patients with tumor size >20 mm. CONCLUSION Recurrence following post-neoadjuvant pancreatectomy is common. Preoperative tumor size <20 mm, normal posttreatment CA19.9 and ΔCA19.9 > 50% were associated with longer RFS. These variables should not be taken in isolation, as their interaction significantly modulates the recurrence risk.
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Affiliation(s)
- Laura Maggino
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, G.B. Rossi Hospital, Verona, Italy
| | - Giuseppe Malleo
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, G.B. Rossi Hospital, Verona, Italy
| | - Stefano Crippa
- Unit of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Giulio Belfiori
- Unit of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Sara Nobile
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, G.B. Rossi Hospital, Verona, Italy
| | - Giulia Gasparini
- Unit of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Gabriella Lionetto
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, G.B. Rossi Hospital, Verona, Italy
| | - Claudio Luchini
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona Hospital Trust, Verona, Italy
| | - Paola Mattiolo
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona Hospital Trust, Verona, Italy
| | - Marco Schiavo-Lena
- Division of Pathology, Pancreas Translational and Clinical Research Center, Vita-Salute University, San Raffaele Scientific Institute, Milan, Italy
| | - Claudio Doglioni
- Division of Pathology, Pancreas Translational and Clinical Research Center, Vita-Salute University, San Raffaele Scientific Institute, Milan, Italy
| | - Aldo Scarpa
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, G.B. Rossi Hospital, Verona, Italy
| | - Massimo Falconi
- Unit of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, G.B. Rossi Hospital, Verona, Italy
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21
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Huang JC, Pan B, Wang HX, Chen Q, He Q, Lyu SC. Prognostic Value of Neoadjuvant Chemotherapy in Patients with Borderline Resectable Pancreatic Carcinoma Followed by Pancreatectomy with Portal Vein Resection and Reconstruction with Venous Allograft. J Clin Med 2022; 11:jcm11247380. [PMID: 36555996 PMCID: PMC9787949 DOI: 10.3390/jcm11247380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 11/29/2022] [Accepted: 12/10/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Neo-adjuvant chemotherapy (NAC) represents one of the current research hotspots in the field of pancreatic ductal adenocarcinoma (PDAC). The aim of this study is to evaluate the prognostic value of NAC in patients with borderline resectable pancreatic cancer (BRPC) followed by pancreatectomy with portal vein (PV) resection and reconstruction with venous allograft (VAG). METHODS Medical records of patients with BPRC who underwent pancreatectomy with concomitant PV resection and reconstruction with VAG between April 2013 and March 2021 were analyzed retrospectively. Outcomes of patients with and without NAC (NAC, Group 1 vs. non-NAC, Group 2) were compared with focus on R0 resection rates, morbidity, and survival. RESULTS Of the 77 patients with pancreatectomy, PV resection and reconstruction with VAG were identified. Overall survival (OS) rates of 0.5-, 1-, and 2-year were 80.5%, 59.7%, and 31.2%, respectively (median survival time, MST, 14 months). Of these, 24 patients (Group 1) underwent operation following received NAC, and the remaining 53 patients did not (Group 2). The R0 resection rate of vascular margin was 100% vs. 84.9% (p = 0.04), respectively. Morbidity of post-operative pancreatic fistula (POPF) was 0% vs. 17.8% (p = 0.07), respectively. The OS of 0.5-, 1- and 2-year and MST of 2 groups were 83.3%, 66.7%, 41.7%, 16 months, and 79.2%, 55.6%, 26.4%, 13 months, respectively. Multivariate analysis revealed that carbohydrate antigen 19-9 (CA19-9) serum level and postoperative chemotherapy were independent prognostic factors in patients with BRPC after surgery. CONCLUSION NAC might improve the R0 resection rate and POPF in patients with BRPC who underwent pancreatectomy with concomitant PV resection and reconstruction with VAG. Survival benefit exists in patients with BRPC who received NAC before pancreatectomy. Postoperative chemotherapy also had a favorable effect on OS of BRPC patients. Elevated CA 19-9 serum level is associated with poor prognosis, even after NAC-combining operation.
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Affiliation(s)
| | | | | | | | - Qiang He
- Correspondence: (Q.H.); (S.-C.L.); Tel.: +86-010-85231504 (Q.H.); +86-010-85231504 (S.-C.L.)
| | - Shao-Cheng Lyu
- Correspondence: (Q.H.); (S.-C.L.); Tel.: +86-010-85231504 (Q.H.); +86-010-85231504 (S.-C.L.)
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22
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Secanella L, Busquets J, Peláez N, Sorribas M, Laquente B, Ruiz S, Carnaval T, Videla S, Fabregat J. Predictive factors for resection and survival in type A borderline resectable pancreatic ductal adenocarcinoma patients after neoadjuvant therapy: A retrospective cohort study. Medicine (Baltimore) 2022; 101:e32126. [PMID: 36482640 PMCID: PMC9726357 DOI: 10.1097/md.0000000000032126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Pancreatic cancer is the seventh leading cause of cancer-related death worldwide, and surgical resection with radical intent remains the only potentially curative treatment option today. However, borderline resectable pancreatic ductal adenocarcinomas (BR-PDAC) stand in the gray area between the resectable and unresectable disease since they are technically resectable but have a high probability of incomplete exeresis. Neoadjuvant treatment (NAT) plays an important role in ensuring resection success.Different survival prognostic factors for BR-PDAC have been well described, but evidence on the predictive factors associated with resection after NAT is scarce. This study aims to study if CA 19-9 plasmatic levels and the tumor anatomical relationship with neighboring vascular structures are prognostic factors for resection and survival (both Overall Survival and Progression-Free Survival) in patients with type A BR-PDAC. METHODS This will be a retrospective cohort study using data from type A BR-PDAC patients who received NAT in the Bellvitge University Hospital. The observation period is from January 2010 until December 2019; patients must have a minimum 12-month follow-up. Patients will be classified according to the MD Anderson Cancer Center criteria for BR-PDAC. DISCUSSION Patients with BR-PDAC have a high risk for a margin-positive resection. Serum Carbohydrate Antigen 19-9 plasmatic levels and vascular involvement stand out as disease-related prognostic factors.This study will provide valuable information on the prognostic factors associated with resection. We will exclude locally advanced tumors and expect this approach to provide more realistic resection rates without selecting those patients that undergo surgical exploration. However, focusing on an anatomical definition may limit the results' generalizability.
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Affiliation(s)
- Luis Secanella
- Digestive and General Surgery Department, Bellvitge University Hospital, L’Hospitalet DE Llobregat, Barcelona, Spain
- Research Group of Hepato-Biliary and Pancreatic Diseases, Institut d’Investigació Biomèdica de Bellvitge – IDIBELL, University of Barcelona, L’Hospitalet DE Llobregat, Barcelona, Spain
| | - Juli Busquets
- Digestive and General Surgery Department, Bellvitge University Hospital, L’Hospitalet DE Llobregat, Barcelona, Spain
- Research Group of Hepato-Biliary and Pancreatic Diseases, Institut d’Investigació Biomèdica de Bellvitge – IDIBELL, University of Barcelona, L’Hospitalet DE Llobregat, Barcelona, Spain
- Departament de Ciències Clíniques, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), C. Casanova, Barcelona, Spain
- *Correspondence: Juli Busquets, Digestive and General Surgery Department, Bellvitge University Hospital, L’Hospitalet DE Llobregat, Barcelona, Spain (e-mail: )
| | - Núria Peláez
- Digestive and General Surgery Department, Bellvitge University Hospital, L’Hospitalet DE Llobregat, Barcelona, Spain
- Research Group of Hepato-Biliary and Pancreatic Diseases, Institut d’Investigació Biomèdica de Bellvitge – IDIBELL, University of Barcelona, L’Hospitalet DE Llobregat, Barcelona, Spain
| | - María Sorribas
- Digestive and General Surgery Department, Bellvitge University Hospital, L’Hospitalet DE Llobregat, Barcelona, Spain
- Research Group of Hepato-Biliary and Pancreatic Diseases, Institut d’Investigació Biomèdica de Bellvitge – IDIBELL, University of Barcelona, L’Hospitalet DE Llobregat, Barcelona, Spain
| | - Berta Laquente
- Medical Oncology Department, Catalan Institute of Oncology, IDIBELL, L’Hospitalet DE Llobregat, Barcelona, Spain
| | - Sandra Ruiz
- Radiology Department, Bellvitge University Hospital, L’Hospitalet DE Llobregat, Barcelona, Spain
| | - Thiago Carnaval
- Pharmacology Unit, Department of Pathology and Experimental Therapeutics, School of Medicine and Health Sciences, IDIBELL, University of Barcelona, L’Hospitalet DE Llobregat, Barcelona, Spain
| | - Sebastián Videla
- Pharmacology Unit, Department of Pathology and Experimental Therapeutics, School of Medicine and Health Sciences, IDIBELL, University of Barcelona, L’Hospitalet DE Llobregat, Barcelona, Spain
- Clinical Research Support Unit (HUB·IDIBELL), Clinical Pharmacology Department, Bellvitge University Hospital, L´Hospitalet DE Llobregat, Barcelona, Spain
| | - Juan Fabregat
- Digestive and General Surgery Department, Bellvitge University Hospital, L’Hospitalet DE Llobregat, Barcelona, Spain
- Research Group of Hepato-Biliary and Pancreatic Diseases, Institut d’Investigació Biomèdica de Bellvitge – IDIBELL, University of Barcelona, L’Hospitalet DE Llobregat, Barcelona, Spain
- Departament de Ciències Clíniques, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), C. Casanova, Barcelona, Spain
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23
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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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24
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Abdelrahman AM, Goenka AH, Alva-Ruiz R, Yonkus JA, Leiting JL, Graham RP, Merrell KW, Thiels CA, Hallemeier CL, Warner SG, Haddock MG, Grotz TE, Tran NH, Smoot RL, Ma WW, Cleary SP, McWilliams RR, Nagorney DM, Halfdanarson TR, Kendrick ML, Truty MJ. FDG-PET Predicts Neoadjuvant Therapy Response and Survival in Borderline Resectable/Locally Advanced Pancreatic Adenocarcinoma. J Natl Compr Canc Netw 2022; 20:1023-1032.e3. [PMID: 36075389 DOI: 10.6004/jnccn.2022.7041] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 06/03/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Neoadjuvant therapy (NAT) is used in borderline resectable/locally advanced (BR/LA) pancreatic ductal adenocarcinoma (PDAC). Anatomic imaging (CT/MRI) poorly predicts response, and biochemical (CA 19-9) markers are not useful (nonsecretors/nonelevated) in many patients. Pathologic response highly predicts survival post-NAT, but is only known postoperatively. Because metabolic imaging (FDG-PET) reveals primary tumor viability, this study aimed to evaluate our experience with preoperative FDG-PET in patients with BR/LA PDAC in predicting NAT response and survival. METHODS We reviewed all patients with resected BR/LA PDAC who underwent NAT with FDG-PET within 60 days of resection. Pre- and post-NAT metabolic (FDG-PET) and biochemical (CA 19-9) responses were dichotomized in addition to pathologic responses. We compared post-NAT metabolic and biochemical responses as preoperative predictors of pathologic responses and recurrence-free survival (RFS) and overall survival (OS). RESULTS We identified 202 eligible patients. Post-NAT, 58% of patients had optimization of CA 19-9 levels. Major metabolic and pathologic responses were present in 51% and 38% of patients, respectively. Median RFS and OS times were 21 and 48.7 months, respectively. Metabolic response was superior to biochemical response in predicting pathologic response (area under the curve, 0.86 vs 0.75; P<.001). Metabolic response was the only univariate preoperative predictor of OS (odds ratio, 0.25; 95% CI, 0.13-0.40), and was highly correlated (P=.001) with pathologic response as opposed to biochemical response alone. After multivariate adjustment, metabolic response was the single largest independent preoperative predictor (P<.001) for pathologic response (odds ratio, 43.2; 95% CI, 16.9-153.2), RFS (hazard ratio, 0.37; 95% CI, 0.2-0.6), and OS (hazard ratio, 0.21; 95% CI, 0.1-0.4). CONCLUSIONS Among patients with post-NAT resected BR/LA PDAC, FDG-PET highly predicts pathologic response and survival, superior to biochemical responses alone. Given the poor ability of anatomic imaging or biochemical markers to assess NAT responses in these patients, FDG-PET is a preoperative metric of NAT efficacy, thereby allowing potential therapeutic alterations and surgical treatment decisions. We suggest that FDG-PET should be an adjunct and recommended modality during the NAT phase of care for these patients.
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Affiliation(s)
| | - Ajit H Goenka
- Division of Nuclear Medicine Radiology, Department of Radiology
| | - Roberto Alva-Ruiz
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery
| | - Jennifer A Yonkus
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery
| | | | - Rondell P Graham
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology
| | | | | | | | - Susanne G Warner
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery
| | | | - Travis E Grotz
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery
| | - Nguyen H Tran
- Division of Medical Oncology, Department of Oncology, Mayo Clinic, Rochester, Minnesota
| | - Rory L Smoot
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery
| | - Wen Wee Ma
- Division of Medical Oncology, Department of Oncology, Mayo Clinic, Rochester, Minnesota
| | - Sean P Cleary
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery
| | - Robert R McWilliams
- Division of Medical Oncology, Department of Oncology, Mayo Clinic, Rochester, Minnesota
| | - David M Nagorney
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery
| | | | | | - Mark J Truty
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery
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25
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Frigerio I, Malleo G, de Pastena M, Deiro G, Surci N, Scopelliti F, Esposito A, Regi P, Giardino A, Allegrini V, Bassi C, Girelli R, Salvia R, Butturini G. Prognostic Factors After Pancreatectomy for Pancreatic Cancer Initially Metastatic to the Liver. Ann Surg Oncol 2022; 29:8503-8510. [PMID: 35976466 PMCID: PMC9383677 DOI: 10.1245/s10434-022-12385-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 07/28/2022] [Indexed: 11/24/2022]
Abstract
Background Resection of initially oligometastatic pancreatic ductal adenocarcinoma (PDAC) following response to first-line chemotherapy is controversial. We herein updated a previous case series to investigate the oncologic outcomes and preoperative factors that could drive the decision-making process. Methods This retrospective analysis was limited to patients with liver-only synchronous metastases who experienced complete regression of the metastatic component and underwent pancreatectomy between October 2008 and July 2020 at two high-volume institutions. Clinical-pathologic variables were captured, and inflammation-based prognostic scores were calculated. Recurrence and survival analyses were performed using standard statistical methods. Results Overall, 52 patients were included. FOLFIRINOX was the most employed chemotherapy regimen (63.5%). Post-treatment tumor size, serum carbohydrate antigen (CA) 19-9 and carcinoembryonic antigen (CEA) were significantly decreased relative to baseline evaluation. The median time from diagnosis to pancreatectomy was 10.2 months, while the median time from chemotherapy completion to pancreatectomy was 2 months. Major postoperative complications occurred in 26.9% of patients, while postoperative mortality was nil. The median disease-free survival (DFS) and overall survival (OS) from pancreatectomy were 16.5 and 23.0 months, respectively, and the median OS from diagnosis was 37.2 months. At multivariable analysis, vascular resection, operative time, prognostic nutrition index (PNI) and neutrophil-to-lymphocyte ratio (NLR) were associated with OS. Operative time, platelet × neutrophil/lymphocyte count (SII), and PNI were associated with DFS. Conclusions We confirm promising outcomes of selected patients who underwent pancreatectomy following downstaging of liver metastases. The absence of vascular involvement of the primary tumor, good nutritional status, and low inflammatory index scores could be useful to select candidates for resection.
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Affiliation(s)
- Isabella Frigerio
- Pancreatic Surgical Unit, Department of General and Vascular Surgery, Pederzoli Hospital, Peschiera del Garda, Verona, Italy.
| | - Giuseppe Malleo
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Matteo de Pastena
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Giacomo Deiro
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Niccolò Surci
- Pancreatic Surgical Unit, Department of General and Vascular Surgery, Pederzoli Hospital, Peschiera del Garda, Verona, Italy.,Department of Surgery, Medical University of Vienna, General Hospital, Vienna, Austria
| | - Filippo Scopelliti
- Pancreatic Surgical Unit, Department of General and Vascular Surgery, Pederzoli Hospital, Peschiera del Garda, Verona, Italy
| | - Alessandro Esposito
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Paolo Regi
- Pancreatic Surgical Unit, Department of General and Vascular Surgery, Pederzoli Hospital, Peschiera del Garda, Verona, Italy
| | - Alessandro Giardino
- Pancreatic Surgical Unit, Department of General and Vascular Surgery, Pederzoli Hospital, Peschiera del Garda, Verona, Italy
| | - Valentina Allegrini
- Pancreatic Surgical Unit, Department of General and Vascular Surgery, Pederzoli Hospital, Peschiera del Garda, Verona, Italy
| | | | - Roberto Girelli
- Pancreatic Surgical Unit, Department of General and Vascular Surgery, Pederzoli Hospital, Peschiera del Garda, Verona, Italy
| | - Roberto Salvia
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Giovanni Butturini
- Pancreatic Surgical Unit, Department of General and Vascular Surgery, Pederzoli Hospital, Peschiera del Garda, Verona, Italy
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26
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Hartlapp I, Valta-Seufzer D, Siveke JT, Algül H, Goekkurt E, Siegler G, Martens UM, Waldschmidt D, Pelzer U, Fuchs M, Kullmann F, Boeck S, Ettrich TJ, Held S, Keller R, Anger F, Germer CT, Stang A, Kimmel B, Heinemann V, Kunzmann V. Prognostic and predictive value of CA 19-9 in locally advanced pancreatic cancer treated with multiagent induction chemotherapy: results from a prospective, multicenter phase II trial (NEOLAP-AIO-PAK-0113). ESMO Open 2022; 7:100552. [PMID: 35970013 PMCID: PMC9434418 DOI: 10.1016/j.esmoop.2022.100552] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 06/30/2022] [Accepted: 07/03/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The prognostic and predictive value of carbohydrate antigen 19-9 (CA 19-9) in locally advanced pancreatic cancer (LAPC) has not yet been defined from prospective randomized controlled trials (RCTs). PATIENTS AND METHODS A total of 165 LAPC patients were treated within the NEOLAP RCT for 16 weeks with multiagent induction chemotherapy [ICT; either nab-paclitaxel/gemcitabine alone or nab-paclitaxel/gemcitabine followed by FOLFIRINOX (combination of fluorouracil, leucovorin, irinotecan, and oxaliplatin)] followed by surgical exploration of all patients without evidence of disease progression. CA 19-9 was determined at baseline and after ICT and correlated with overall survival (OS) and secondary R0 resection rate. RESULTS From the NEOLAP study population (N = 165) 133 patients (81%) were evaluable for CA 19-9 at baseline and 81/88 patients (92%) for post-ICT CA 19-9 response. Median OS (mOS) in the CA 19-9 cohort (n = 133) was 16.2 months [95% confidence interval (CI) 13.0-19.4] and R0 resection (n = 31; 23%) was associated with a significant survival benefit [40.8 months (95% CI 21.7-59.8)], while R1 resected patients (n = 14; 11%) had no survival benefit [14.0 (95% CI 11.7-16.3) months, hazard ratio (HR) 0.27; P = 0.001]. After ICT most patients showed a CA 19-9 response (median change from baseline: -82%; relative decrease ≥55%: 83%; absolute decrease to ≤50 U/ml: 43%). Robust CA 19-9 response (decrease to ≤50U/ml) was significantly associated with mOS [27.8 (95% CI 18.4-37.2) versus 16.5 (95% CI 11.7-21.2) months, HR 0.49; P = 0.013], whereas CA 19-9 baseline levels were not prognostic for OS. Multivariate analysis demonstrated that a robust CA 19-9 response was an independent predictive factor for R0 resection. Using a CA 19-9 decrease to ≤61 U/ml as optimal cut-off (by receiver operating characteristic analysis) yielded 72% sensitivity and 62% specificity for successful R0 resection, whereas CA 19-9 nonresponders (<20% decrease or increase) had no chance for successful R0 resection. CONCLUSIONS CA 19-9 response after multiagent ICT provides relevant prognostic and predictive information and is useful in selecting LAPC patients for explorative surgery. CLINICAL TRIAL NUMBER ClinicalTrials.govNCT02125136; https://clinicaltrials.gov/ct2/show/NCT02125136; EudraCT 2013-004796-12; https://www.clinicaltrialsregister.eu/ctr-search/trial/2013-004796-12/results.
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Affiliation(s)
- I Hartlapp
- Department of Internal Medicine II, Medical Oncology and Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, Würzburg, Germany
| | - D Valta-Seufzer
- Department of Internal Medicine II, Medical Oncology and Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, Würzburg, Germany
| | - J T Siveke
- Department of Medical Oncology, Bridge Institute of Experimental Tumor Therapy, University Medicine Essen, Essen, Germany; Division of Solid Tumor Translational Oncology (DKTK Partner Site Essen, DKFZ Heidelberg), West German Cancer Center, University Medicine Essen, Essen, Germany
| | - H Algül
- Comprehensive Cancer Center Munich (CCCM(TUM)) at the Klinikum rechts der Isar, Department of Internal Medicine II, Technical University Munich, Munich, Germany
| | - E Goekkurt
- Hämatologisch-Onkologische Praxis Eppendorf (HOPE), Hamburg and University Cancer Center Hamburg (UCCH), Hamburg, Germany
| | - G Siegler
- Department of Internal Medicine 5, Hematology and Medical Oncology, Paracelsus Medical University, Nürnberg, Germany
| | - U M Martens
- Department of Internal Medicine III, SLK-Clinics Heilbronn GmbH, Heilbronn, Germany
| | - D Waldschmidt
- Department of Gastroenterology and Hepatology, University Hospital Cologne, Cologne, Germany
| | - U Pelzer
- Division of Oncology and Hematology, Charité Campus Mitte, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - M Fuchs
- Clinic for Gastroenterology, Hepatology and GI-Oncology, München Klinik Bogenhausen, Munich, Germany
| | - F Kullmann
- Department of Internal Medicine I, Kliniken Nordoberpfalz AG, Klinikum Weiden, Weiden, Germany
| | - S Boeck
- Department of Medical Oncology and Comprehensive Cancer Center, Ludwig Maximilians University-Grosshadern, Munich, Germany
| | - T J Ettrich
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
| | - S Held
- Department of Biometrics, ClinAssess GmbH, Leverkusen, Germany
| | - R Keller
- Clinical Research, AIO Studien gGmbH, Berlin, Germany
| | - F Anger
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery and Comprehensive Cancer Center Mainfranken Würzburg, University Hospital Würzburg, Würzburg, Germany
| | - C T Germer
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery and Comprehensive Cancer Center Mainfranken Würzburg, University Hospital Würzburg, Würzburg, Germany
| | - A Stang
- Department of Haematology, Oncology and Palliative Care Medicine, Asklepios Hospital Barmbek, Hamburg, Germany
| | - B Kimmel
- Department of Internal Medicine II, Medical Oncology and Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, Würzburg, Germany
| | - V Heinemann
- Department of Medical Oncology and Comprehensive Cancer Center, Ludwig Maximilians University-Grosshadern, Munich, Germany
| | - V Kunzmann
- Department of Internal Medicine II, Medical Oncology and Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, Würzburg, Germany.
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Gyftopoulos A, Ziogas IA, Barbas AS, Moris D. The Synergistic Role of Irreversible Electroporation and Chemotherapy for Locally Advanced Pancreatic Cancer. Front Oncol 2022; 12:843769. [PMID: 35692753 PMCID: PMC9174659 DOI: 10.3389/fonc.2022.843769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 04/26/2022] [Indexed: 12/11/2022] Open
Abstract
Irreversible electroporation (IRE) is a local ablative technique used in conjunction with chemotherapy to treat locally advanced pancreatic cancer (LAPC). The combination of IRE and chemotherapy has showed increased overall survival when compared to chemotherapy alone, pointing towards a possible facilitating effect of IRE on chemotherapeutic drug action and delivery. This review aims to present current chemotherapeutic regimens for LAPC and their co-implementation with IRE, with an emphasis on possible molecular augmentative mechanisms of drug delivery and action. Moreover, the potentiating mechanism of IRE on immunotherapy, M1 oncolytic virus and dendritic cell (DC)-based treatments is briefly explored. Investigating the synergistic effect of IRE on currently established treatment regimens as well as newer ones, may present exciting new possibilities for future studies seeking to improve current LAPC treatment algorithms.
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Affiliation(s)
| | - Ioannis A Ziogas
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Andrew S Barbas
- Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Durham, NC, United States
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Shi Z, Yang J, Kong W, Qiu X, Lu C, Liu J, Liu B, Du J. Use of Nab-Paclitaxel Plus Gemcitabine Followed by Hypofractionated Tomotherapy With Simultaneous Integrated Boost in Patients With Locally Advanced Pancreatic Cancer. Front Oncol 2022; 12:782730. [PMID: 35299738 PMCID: PMC8922029 DOI: 10.3389/fonc.2022.782730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 01/31/2022] [Indexed: 12/24/2022] Open
Abstract
Background and Purpose A phase 2 study LAPACT indicated nab-paclitaxel plus gemcitabine (AG) improved outcomes of patients with locally advanced pancreatic cancer (LAPC). Conventional radiotherapy failed to show benefit, indicating high dose to volume with high risk of recurrence is needed. The high dose can be delivered through hypofractionated tomotherapy with simultaneous integrated boost (SIB). However, there is a lack of such prospective trials and more data are needed to validate the role of AG plus hypofractionated tomotherapy with SIB in patients with LAPC. Materials and Methods Patients with LAPC receiving AG plus tomotherapy at the Nanjing Drum Tower Hospital between 2018 and 2021 were retrospectively analyzed. The treatment was scheduled as follows: nab-paclitaxel 125 mg/m2 plus gemcitabine 1,000 mg/m2 on days 1 and 8 every three weeks for at least two cycles, followed by hypofractionated tomotherapy with SIB (high dose field: 50 Gy/10 fractions, the remainder: 30 Gy/10 fractions). Then patients were given AG until intolerance or disease progression. Results Overall, 22 patients completing the chemoradiotherapy were included. The median follow-up was 15.2 months. After the chemoradiotherapy, 5 patients achieved a partial response (PR), 15 had a stable disease (SD), and another 2 patients were with progressive disease (PD). The median progression-free survival (PFS) and overall survival (OS) were 12.8 months (95% confidence interval [CI] 4.3-21.3 months) and 16.3 months (95% CI 10.9-21.6 months), respectively. The optimal carbohydrate antigen (CA) 19-9 response and chemotherapy cycles ≥6 were correlated with favorable PFS and OS. The most common recurrent pattern was peritoneal dissemination (22.7%) and the locoregional recurrence rate was relatively low (4.5%). Treatments were well-tolerated. The most common grade ≥3 adverse event was thrombocytopenia (13.6%). Conclusion This study demonstrated the feasibility of AG followed by hypofractionated tomotherapy with SIB in patients with LAPC. The hypofractionated tomotherapy with SIB was safe and showed high local control rate. Further study with a larger population to validate our data is underway.
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Affiliation(s)
- Zhan Shi
- The Comprehensive Cancer Centre of Drum Tower Hospital, Medical School of Nanjing University, Clinical Cancer Institute of Nanjing University, Nanjing, China
| | - Ju Yang
- The Comprehensive Cancer Centre of Drum Tower Hospital, Medical School of Nanjing University, Clinical Cancer Institute of Nanjing University, Nanjing, China
| | - Weiwei Kong
- The Comprehensive Cancer Centre of Drum Tower Hospital, Medical School of Nanjing University, Clinical Cancer Institute of Nanjing University, Nanjing, China
| | - Xin Qiu
- The Comprehensive Cancer Center of Drum Tower Hospital, Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
| | - Changchang Lu
- The Comprehensive Cancer Center of Drum Tower Hospital, Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
| | - Juan Liu
- The Comprehensive Cancer Centre of Drum Tower Hospital, Medical School of Nanjing University, Clinical Cancer Institute of Nanjing University, Nanjing, China
| | - Baorui Liu
- The Comprehensive Cancer Centre of Drum Tower Hospital, Medical School of Nanjing University, Clinical Cancer Institute of Nanjing University, Nanjing, China
| | - Juan Du
- The Comprehensive Cancer Centre of Drum Tower Hospital, Medical School of Nanjing University, Clinical Cancer Institute of Nanjing University, Nanjing, China
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Rossi G, Altabella L, Simoni N, Benetti G, Rossi R, Venezia M, Paiella S, Malleo G, Salvia R, Guariglia S, Bassi C, Cavedon C, Mazzarotto R. Computed tomography-based radiomic to predict resectability in locally advanced pancreatic cancer treated with chemotherapy and radiotherapy. World J Gastrointest Oncol 2022; 14:703-715. [PMID: 35321278 PMCID: PMC8919018 DOI: 10.4251/wjgo.v14.i3.703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/06/2021] [Accepted: 02/13/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Surgical resection after neoadjuvant treatment is the main driver for improved survival in locally advanced pancreatic cancer (LAPC). However, the diagnostic performance of computed tomography (CT) imaging to evaluate the residual tumour burden at restaging after neoadjuvant therapy is low due to the difficulty in distinguishing neoplastic tissue from fibrous scar or inflammation. In this context, radiomics has gained popularity over conventional imaging as a complementary clinical tool capable of providing additional, unprecedented information regarding the intratumor heterogeneity and the residual neoplastic tissue, potentially serving in the therapeutic decision-making process.
AIM To assess the capability of radiomic features to predict surgical resection in LAPC treated with neoadjuvant chemotherapy and radiotherapy.
METHODS Patients with LAPC treated with intensive chemotherapy followed by ablative radiation therapy were retrospectively reviewed. One thousand six hundred and fifty-five radiomic features were extracted from planning CT inside the gross tumour volume. Both extracted features and clinical data contribute to create and validate the predictive model of resectability status. Patients were repeatedly divided into training and validation sets. The discriminating performance of each model, obtained applying a LASSO regression analysis, was assessed with the area under the receiver operating characteristic curve (AUC). The validated model was applied to the entire dataset to obtain the most significant features.
RESULTS Seventy-one patients were included in the analysis. Median age was 65 years and 57.8% of patients were male. All patients underwent induction chemotherapy followed by ablative radiotherapy, and 19 (26.8%) ultimately received surgical resection. After the first step of variable selections, a predictive model of resectability was developed with a median AUC for training and validation sets of 0.862 (95%CI: 0.792-0.921) and 0.853 (95%CI: 0.706-0.960), respectively. The validated model was applied to the entire dataset and 4 features were selected to build the model with predictive performance as measured using AUC of 0.944 (95%CI: 0.892-0.996).
CONCLUSION The present radiomic model could help predict resectability in LAPC after neoadjuvant chemotherapy and radiotherapy, potentially integrating clinical and morphological parameters in predicting surgical resection.
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Affiliation(s)
- Gabriella Rossi
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona 37126, Italy
| | - Luisa Altabella
- Department of Medical Physics, University of Verona Hospital Trust, Verona 37126, Italy
| | - Nicola Simoni
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona 37126, Italy
| | - Giulio Benetti
- Department of Medical Physics, University of Verona Hospital Trust, Verona 37126, Italy
| | - Roberto Rossi
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona 37126, Italy
| | - Martina Venezia
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona 37126, Italy
| | - Salvatore Paiella
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona 37126, Italy
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona 37126, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona 37126, Italy
| | - Stefania Guariglia
- Department of Medical Physics, University of Verona Hospital Trust, Verona 37126, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona 37126, Italy
| | - Carlo Cavedon
- Department of Medical Physics, University of Verona Hospital Trust, Verona 37126, Italy
| | - Renzo Mazzarotto
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona 37126, Italy
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Li H, Feng Y, Liu C, Li J, Li J, Wu H, Wang G, Li D. Importance of Normalization of Carbohydrate Antigen 19-9 in Patients With Intrahepatic Cholangiocarcinoma. Front Oncol 2021; 11:780455. [PMID: 35004301 PMCID: PMC8728073 DOI: 10.3389/fonc.2021.780455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 11/30/2021] [Indexed: 01/06/2023] Open
Abstract
Background Although carbohydrate antigen 19-9 (CA19-9) is an established prognostic marker for intrahepatic cholangiocarcinoma (ICC) patients, the significance of elevated preoperative CA19-9 that normalized after resection remains unknown. This study aimed to investigate whether elevated preoperative CA19-9 that normalized after curative resection had an impact on prognosis among patients with ICC. Methods Patients who underwent curative resection for stage I to III ICC between 2009 and 2018 were identified. Patients were categorized into three cohorts: normal preoperative CA19-9, elevated preoperative CA19-9 but normalized postoperative CA19-9, and persistently elevated postoperative CA19-9. Overall survival (OS), recurrence-free survival (RFS), and hazard function curves over time were analyzed. Results A total of 511 patients (247 [48.3%] male; median age, 58 years) were included. Patients with elevated preoperative CA19-9 (n = 378) were associated with worse RFS and OS than those with normal preoperative CA19-9 (n = 152) (both p < 0.001). Patients with persistently elevated postoperative CA19-9 (n = 254) were correlated with lower RFS and OS than the combined cohorts with normal postoperative CA19-9 (n = 257) (both p < 0.001). The hazard function curves revealed that the risk of recurrence and mortality peaked earlier and higher in the elevated postoperative CA19-9 group than the other 2 groups. Multivariate analyses identified persistently elevated, rather than normalized, postoperative CA19-9 as an independent risk factor for shorter RFS and OS in ICC. Conclusions Elevated preoperative serum CA19-9 that normalizes after curative resection is not an indicator of poor prognosis in ICC. Patients with persistently elevated postoperative CA19-9 are at increased risk of recurrence and death.
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Affiliation(s)
- Hui Li
- Department of Liver Surgery & Liver Transplantation, West China Hospital, Sichuan University, Chengdu, China
- Department of Hepatobiliary Pancreatic Tumor Center, Chongqing University Cancer Hospital, Chongqing, China
| | - Yuan Feng
- Department of Liver Surgery & Liver Transplantation, West China Hospital, Sichuan University, Chengdu, China
- Department of General Surgery, Nanping District People's Hospital, Nanchong, China
| | - Chang Liu
- Department of Liver Surgery & Liver Transplantation, West China Hospital, Sichuan University, Chengdu, China
| | - Jiawang Li
- Department of Hepatobiliary Pancreatic Tumor Center, Chongqing University Cancer Hospital, Chongqing, China
| | - Jiaxin Li
- Department of Liver Surgery & Liver Transplantation, West China Hospital, Sichuan University, Chengdu, China
| | - Hong Wu
- Department of Liver Surgery & Liver Transplantation, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Dewei Li, ; Genshu Wang, ; Hong Wu,
| | - Genshu Wang
- Department of Hepatic Surgery and Liver Transplantation Center, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- *Correspondence: Dewei Li, ; Genshu Wang, ; Hong Wu,
| | - Dewei Li
- Department of Hepatobiliary Pancreatic Tumor Center, Chongqing University Cancer Hospital, Chongqing, China
- *Correspondence: Dewei Li, ; Genshu Wang, ; Hong Wu,
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Evolving pancreatic cancer treatment: From diagnosis to healthcare management. Crit Rev Oncol Hematol 2021; 169:103571. [PMID: 34923121 DOI: 10.1016/j.critrevonc.2021.103571] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 12/13/2021] [Indexed: 12/12/2022] Open
Abstract
The prognosis of pancreatic ductal adenocarcinoma is still the worst among solid tumors. In this review, a panel of experts addressed the main unanswered questions about the clinical management of this disease, with the aim of providing practical decision support for physicians. On the basis of the evidence available from the literature, the main topics concerning pancreatic cancer are discussed: the diagnosis, as the need for a pathological characterization and the role for germ-line and somatic molecular profiling; the therapeutic management of resectable disease, as the role of upfront surgery or neoadjuvant chemotherapy, the post-operative restaging and the optimal timing foradjuvant chemotherapy, the management of the borderline resectable and locally advanced disease; the metastatic disease and the role of surgery for the management of patients with isolated metastasis and the use of biomarkers of metastatic potential; the role of supportive care and the healthcare management of pancreatic ductal adenocarcinoma.
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Hammel P, Carrier E, Carney M, Eisner M, Fleming T. A novel event-free survival endpoint in locally advanced pancreatic cancer. Ther Adv Med Oncol 2021; 13:17588359211059586. [PMID: 34868352 PMCID: PMC8640304 DOI: 10.1177/17588359211059586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 10/25/2021] [Indexed: 11/16/2022] Open
Abstract
The treatment paradigm for locally advanced pancreatic cancer (LAPC) is evolving rapidly. The development of neoadjuvant therapies composed of combination therapies and the evaluation of their impact on conversion to borderline resectable (BR) status, resection, and ultimately overall survival (OS) are presently being pursued. These efforts justify re-visiting study endpoints in order to better predict therapeutic effects on OS, by capturing not only the achievement of R0 resection at the end of induction therapy but also the long-term reductions in the rate of local and distal recurrence. The proposed herein event-free survival (EFS) endpoint, with its novel definition specific to LAPC, is formulated to achieve these objectives. It is an analog to disease-free survival (DFS) endpoint in the adjuvant setting applied to the neoadjuvant setting and may be a valuable surrogate endpoint for this patient population.
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Affiliation(s)
- Pascal Hammel
- Digestive and Medical Oncology Department, Hospital Paul Brousse, University Paris-Saclay, 94800 Villejuif, France
| | - Ewa Carrier
- Department of Clinical Development, FibroGen, Inc., San Francisco, CA, USA
| | - Mairead Carney
- Department of Clinical Development, FibroGen, Inc., San Francisco, CA, USA
| | - Mark Eisner
- Department of Clinical Development, FibroGen, Inc., San Francisco, CA, USA
| | - Thomas Fleming
- Department of Biostatistics, University of Washington, Seattle, WA, USA
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Comments on "Importance of Normalization of CA19-9 Levels After Neoadjuvant Therapy in Patients With Localized Pancreatic Cancer". Ann Surg 2021; 274:e800-e801. [PMID: 33065647 DOI: 10.1097/sla.0000000000004538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Can a simplified CT response criteria for vascular involvement in pancreatic adenocarcinoma after neoadjuvant therapy predict survival in patients who achieved subsequent R0 resection? Abdom Radiol (NY) 2021; 46:5609-5617. [PMID: 34557934 DOI: 10.1007/s00261-021-03284-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 09/08/2021] [Accepted: 09/09/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE To investigate if a simplified image based scoring system assessing treatment response after neoadjuvant therapy (NAT) can predict survival in patients with pancreatic ductal adenocarcinoma (PDAC) who achieved subsequent R0 resection. METHODS Retrospective analysis of 57 PDAC patients (male = 29, 51%) with mean age of 64 at diagnosis (range 42-79) who received NAT and R0 resection. Post-NAT overall, arterial and venous imaging response was characterized as improved, similar, or worse by 2 readers independently followed by consensus review. Kaplan-Meier Analysis was performed to compare overall survival (OS) with post-NAT overall imaging response. A Multivariable Cox proportional hazards analysis was performed to evaluate the association of the following variables with OS: overall, arterial and venous radiology response, clinical staging, postoperative CA19-9, and patient age. RESULTS At study conclusion, 30/57 patients were deceased (53%), 26/57 (46%) alive, and 1 patient unknown. Post-NAT, 39/57 (68.4%) had overall improved disease and 18/57 (31.6%) had similar disease. The median OS was 55.7 months (95% CI 33.4-not reached, NR) for those with improved disease vs. 53.9 months (95% CI 14.3-NR) with similar disease (p = 0.859) after NAT. Among all clinical parameters, only post-operative CA 19-9 level was associated with OS (p = 0.002) and PFS (p = 0.005), respectively. CONCLUSION Pancreatic cancer patients who underwent R0 resection showed no difference in survival when comparing those with similar vs improved disease on post-NAT imaging.
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Nab-paclitaxel plus S-1 with or without PD-1 inhibitor in pancreatic ductal adenocarcinoma with only hepatic metastases: a retrospective cohort study. Langenbecks Arch Surg 2021; 407:633-643. [PMID: 34518900 DOI: 10.1007/s00423-021-02321-7] [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: 06/06/2021] [Accepted: 08/27/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The evidence regarding programmed cell death 1 (PD-1) inhibitors on pancreatic ductal adenocarcinoma (PDAC) with metastases remains controversial. This study aimed to assess the efficacy and safety of Nab-paclitaxel plus S1 (NPS) with or without Sintilimab, a PD-1 inhibitor, in patients with PDAC with only hepatic metastases (mPDAC). METHODS Untreated mPDAC patients who received NPS with (the combination group) or without Sintilimab (the NPS group) were retrospectively studied. Surgery was considered when the pancreatic tumor became resectable or borderline resectable on radiological examinations, and with complete metabolic response of liver metastases. RESULTS Between October 2017 and February 2020, 32 patients were in the combination group and 34 patients in the NPS group. Successful salvage resection was achieved in 17 (25.8%) patients after tumor-downstaging (combination 12 vs. NPS 5, P = 0.03). The median overall survival (OS) was 16.8 months in the combination group and 10.0 months in the NPS group (P = 0.002). Remarkable OS benefit was observed in patients with decline in CA19-9 of ≥ 50% (16.0 vs. 6.5, P = 0.003), reduction in 18F-fluorodeoxyglucose uptake of primary tumor of ≥ 50% (16.5 vs. 10.0, P < 0. 001) and after salvage resection (20.1 vs. 11.0, P < 0. 001). No significant difference in Grade 3 or higher adverse events were seen between the two groups (40.6% vs. 32.4%, P = 0.49). CONCLUSIONS Despite the inherent biases of this retrospective study, the addition of Sintilimab significantly improved salvage resection rates and OS compared with the NPS regimen and had a favorable safety profile in treatment naïve mPDAC patients.
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Damm M, Efremov L, Birnbach B, Terrero G, Kleeff J, Mikolajczyk R, Rosendahl J, Michl P, Krug S. Efficacy and Safety of Neoadjuvant Gemcitabine Plus Nab-Paclitaxel in Borderline Resectable and Locally Advanced Pancreatic Cancer-A Systematic Review and Meta-Analysis. Cancers (Basel) 2021; 13:cancers13174326. [PMID: 34503138 PMCID: PMC8430874 DOI: 10.3390/cancers13174326] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/18/2021] [Accepted: 08/23/2021] [Indexed: 12/20/2022] Open
Abstract
Simple Summary Due to the availability of effective combination chemotherapies such as gemcitabine/nab-paclitaxel (GNP) or FOLFIRINOX, neoadjuvant treatment of borderline resectable (BRPC) and locally advanced pancreatic cancer (LAPC) has been increasingly investigated in recent years. However, due to toxicity, FOLFIRINOX is only available for selected patients and data on GNP are scarce. The aim of this systematic review and meta-analysis, which is to our knowledge the first addressing this question, is to evaluate the value of GNP in patients with BRPC and LAPC. We provide a comprehensive overview on data of 21 studies, comprising 950 patients treated with neoadjuvant GNP. The pooled overall and R0 resection rates were 36% and 26%, respectively. Resection rates were higher in BRPC (49%) compared to LAPC (16%). With acceptable toxicity and a median overall survival rate ranging from 12 to 30 months, neoadjuvant GNP has considerable value in this setting, with more prospective trials being warranted. Abstract Therapy with gemcitabine and nab-paclitaxel (GNP) is the most commonly used palliative chemotherapy, but its advantage in the neoadjuvant setting remains unclear. Accordingly, our aim is to evaluate the impact of first-line neoadjuvant therapy with GNP in patients with borderline resectable (BRPC) and locally advanced pancreatic cancer (LAPC). A systematic search for published studies until August 2020 was performed. The primary endpoint included resection and R0 resection rates in the intention-to-treat population. Secondary endpoints were response rate, survival and toxicity. Among 21 studies, 950 patients who received neoadjuvant GNP were evaluated. Treatment with GNP resulted in surgical resection and R0 resection rates as follows: 49% (95% CI 30–68%) and 36% (95% CI 17–58%) for BRPC and 16% (95% CI 7–26%) and 11% (95% CI 5–19%) for LAPC, respectively. The objective response rates and the median overall survival (mOS) ranged from 0 to 67% and 12 to 30 months, respectively. Neutropenia (range 5–77%) and neuropathy (range 0–22%) were the most commonly reported grade 3 to 4 adverse events. Neoadjuvant chemotherapy with GNP can be performed safely and with valuable effects in patients with BRPC and LAPC. The utility of GNP in comparison to FOLFIRINOX in the neoadjuvant setting requires further investigation in prospective randomized trials.
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Affiliation(s)
- Marko Damm
- Department of Internal Medicine I, University Hospital Halle, Martin-Luther-University Halle-Wittenberg, D-06120 Halle (Saale), Germany; (M.D.); (J.R.); (S.K.)
| | - Ljupcho Efremov
- Institute for Medical Epidemiology, Biometrics and Informatics (IMEBI), Interdisciplinary Center for Health Sciences, Martin-Luther-University Halle-Wittenberg, D-06112 Halle (Saale), Germany; (L.E.); (B.B.); (R.M.)
- Department of Radiation Oncology, Martin-Luther-University Halle-Wittenberg, D-06120 Halle (Saale), Germany
| | - Benedikt Birnbach
- Institute for Medical Epidemiology, Biometrics and Informatics (IMEBI), Interdisciplinary Center for Health Sciences, Martin-Luther-University Halle-Wittenberg, D-06112 Halle (Saale), Germany; (L.E.); (B.B.); (R.M.)
| | - Gretel Terrero
- Department of Medicine, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL 33136, USA;
| | - Jörg Kleeff
- Department of Surgery, University Hospital Halle, Martin-Luther-University Halle-Wittenberg, D-06120 Halle (Saale), Germany;
| | - Rafael Mikolajczyk
- Institute for Medical Epidemiology, Biometrics and Informatics (IMEBI), Interdisciplinary Center for Health Sciences, Martin-Luther-University Halle-Wittenberg, D-06112 Halle (Saale), Germany; (L.E.); (B.B.); (R.M.)
| | - Jonas Rosendahl
- Department of Internal Medicine I, University Hospital Halle, Martin-Luther-University Halle-Wittenberg, D-06120 Halle (Saale), Germany; (M.D.); (J.R.); (S.K.)
| | - Patrick Michl
- Department of Internal Medicine I, University Hospital Halle, Martin-Luther-University Halle-Wittenberg, D-06120 Halle (Saale), Germany; (M.D.); (J.R.); (S.K.)
- Correspondence: ; Tel.: +49-345-557-2661; Fax: +49-345-557-2653
| | - Sebastian Krug
- Department of Internal Medicine I, University Hospital Halle, Martin-Luther-University Halle-Wittenberg, D-06120 Halle (Saale), Germany; (M.D.); (J.R.); (S.K.)
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Passardi A, Rapposelli IG, Scarpi E, Sullo FG, Bartolini G, Neri E, Ghigi G, Tontini L, Ercolani G, Monti M, Ruscelli S, Matteucci L, Valgiusti M, Frassineti GL, Romeo A. Multimodal Treatment with GEMOX Plus Helical Tomotherapy in Unresectable Locally Advanced Pancreatic Cancer: A Pooled Analysis of Two Phase 2 Studies. Biomolecules 2021; 11:biom11081200. [PMID: 34439866 PMCID: PMC8393939 DOI: 10.3390/biom11081200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/29/2021] [Accepted: 08/09/2021] [Indexed: 12/29/2022] Open
Abstract
In locally advanced pancreatic cancer (LAPC), the combination of chemotherapy and radiotherapy is a widely used treatment option. We performed a pooled analysis, including an exploratory analysis for prognostic and predictive factors, of two phase 2 trials including 73 patients with LAPC, treated with gemcitabine and oxaliplatin (GEMOX) and hypofractionated tomotherapy. With a median follow-up of 36 months (range 1–65), median progression-free (PFS) and overall survival (OS) were 10.2 (95% confidence interval [CI] 7.8–13.2) and 14.3 (95% CI 12.0–18.1) months, respectively. The overall resectability rate was 23.3% (95% CI 13.6–33.0), and the R0 resection rate was 13.7% (95% CI 5.8–21.6). In the multivariate analysis, ECOG performance status (PS) 0 and low levels of CA 19–9 were associated with improved OS and PFS. Concerning OS, log(CA19–9) resulted in a hazard ratio (HR) of 1.20 (95% CI 1.02–1.42), p = 0.027. For ECOG PS 0, HR was 1.00; for PS 1, HR was 2.69 (95% CI 1.46–4.96); for PS 2, HR was 4.18 (95% CI 0.90–19.46); p = 0.003. Low CA19–9 levels were also predictive for resection, with an odds ratio of 0.71 (95% CI 0.52–0.97), p = 0.034. In conclusion, GEMOX and hypofractionated radiotherapy is a treatment option in LAPC. Further studies are needed to identify differences in tumor biology, which may help to predict resectability and prognosis.
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Affiliation(s)
- Alessandro Passardi
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
| | - Ilario Giovanni Rapposelli
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
- Correspondence: ; Tel.: +39-0543-739100
| | - Emanuela Scarpi
- Unit of Biostatistics and Clinical Trials, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy;
| | - Francesco Giulio Sullo
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
| | - Giulia Bartolini
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
| | - Elisa Neri
- Radiotherapy Unit, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (E.N.); (G.G.); (L.T.); (A.R.)
| | - Giulia Ghigi
- Radiotherapy Unit, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (E.N.); (G.G.); (L.T.); (A.R.)
| | - Luca Tontini
- Radiotherapy Unit, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (E.N.); (G.G.); (L.T.); (A.R.)
| | - Giorgio Ercolani
- General and Oncologic Surgery Unit, Morgagni-Pierantoni Hospital, AUSL Romagna, 47121 Forlì, Italy;
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy
| | - Manlio Monti
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
| | - Silvia Ruscelli
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
| | - Laura Matteucci
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
| | - Martina Valgiusti
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
| | - Giovanni Luca Frassineti
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
| | - Antonino Romeo
- Radiotherapy Unit, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (E.N.); (G.G.); (L.T.); (A.R.)
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Crippa S, Belfiori G, Tamburrino D, Partelli S, Falconi M. Indications to total pancreatectomy for positive neck margin after partial pancreatectomy: a review of a slippery ground. Updates Surg 2021; 73:1219-1229. [PMID: 34331677 DOI: 10.1007/s13304-021-01141-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 07/23/2021] [Indexed: 12/23/2022]
Abstract
The extension of a partial pancreatectomy up to total pancreatectomy because of positive neck margin examined at intraoperative frozen section (IFS) analysis is an accepted procedure in modern pancreatic surgery with good accuracy. The goal of this practice is to improve the rate of radical (R0) resection in malignant tumors, mainly pancreatic ductal adenocarcinoma (PDAC), and to completely resect pre-invasive neoplasms such as intraductal papillary mucinous neoplasms (IPMNs). In the setting of IPMNs there is a consensus for pancreatic re-resection when high-grade dysplasia and invasive cancer are present at the neck margin. The presence of denudation is another indication for further resection in IPMNs. The role of IFS analysis in the management of pancreatic cancer is more debated. The presence of a positive intraoperative transection margin can be considered the surrogate of a biologically aggressive disease associated with a poorer prognosis. There are conflicting data regarding possible advantages of pancreatic re-resection up to total pancreatectomy, and the lack of randomized trials comparing different strategies does not offer a definitive answer. The goal of this review is to provide an up-to-date overview of the role IFS analysis of pancreatic margin and of pancreatic re-resection up to total pancreatectomy considering different pancreatic tumors.
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Affiliation(s)
- Stefano Crippa
- School of Medicine, Vita Salute San Raffaele University, Milan, Italy.,Division of Pancreatic Surgery, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Giulio Belfiori
- School of Medicine, Vita Salute San Raffaele University, Milan, Italy.,Division of Pancreatic Surgery, IRCCS Ospedale San Raffaele, Milan, Italy
| | | | - Stefano Partelli
- School of Medicine, Vita Salute San Raffaele University, Milan, Italy.,Division of Pancreatic Surgery, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Massimo Falconi
- School of Medicine, Vita Salute San Raffaele University, Milan, Italy. .,Division of Pancreatic Surgery, IRCCS Ospedale San Raffaele, Milan, Italy. .,Department of Surgery, Division of Pancreatic Surgery, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
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39
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Survival Benefit Associated With Resection of Locally Advanced Pancreatic Cancer Following Upfront FOLFIRINOX versus FOLFIRINOX Only: Multicenter Propensity Score-Matched Analysis. Ann Surg 2021; 274:729-735. [PMID: 34334641 DOI: 10.1097/sla.0000000000005120] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study compared median overall survival (OS) after resection of locally advanced pancreatic cancer (LAPC) following upfront FOLFIRINOX versus a propensity-score matched cohort of LAPC patients treated with FOLFIRINOX-only (i.e. without resection). BACKGROUND Since the introduction of FOLFIRINOX chemotherapy, increased resection rates in LAPC patients have been reported, with improved OS. Some studies have also reported promising OS with FOLFIRINOX-only treatment in LAPC. Multicenter studies assessing the survival benefit associated with resection of LAPC versus patients treated with FOLFIRINOX-only are lacking. METHODS Patients with non-progressive LAPC after 4 cycles of FOLFIRINOX treatment, both with and without resection, were included from a prospective multicenter cohort in 16 centers (April 2015-December 2019). Cox regression analysis identified predictors for OS. One-to-one propensity score matching (PSM) was used to obtain a matched cohort of patients with and without resection. These patients were compared for OS. RESULTS Overall, 293 patients with LAPC were included, of whom 89 underwent a resection. Resection was associated with improved OS (24 vs 15 months, p<0.01), as compared to patients without resection. Before PSM, resection, Charlson Comorbidity Index, and RECIST response were predictors for OS. After PSM, resection remained associated with improved OS (HR 0.344, 95% CI [0.222-0.534], p<0.01), with an OS of 24 vs 15 months, as compared to patients without resection. Resection of LAPC was associated with improved 3-year OS (31% vs 11%, p<0.01). CONCLUSION Resection of LAPC following FOLFIRINOX was associated with increased OS and 3-year survival, as compared to propensity-score matched patients treated with FOLFIRINOX-only.
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40
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Picozzi V, Alseidi A, Winter J, Pishvaian M, Mody K, Glaspy J, Larson T, Matrana M, Carney M, Porter S, Kouchakji E, Rocha F, Carrier E. Gemcitabine/nab-paclitaxel with pamrevlumab: a novel drug combination and trial design for the treatment of locally advanced pancreatic cancer. ESMO Open 2021; 5:S2059-7029(20)32637-5. [PMID: 32817130 PMCID: PMC7440698 DOI: 10.1136/esmoopen-2019-000668] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/16/2020] [Accepted: 04/21/2020] [Indexed: 01/06/2023] Open
Abstract
Purpose Pancreatic ductal adenocarcinomas exhibit a high degree of desmoplasia due to extensive extracellular matrix deposition. Encasement of mesenteric vessels by stroma in locally advanced pancreatic cancer (LAPC) prevents surgical resection. This study sought to determine if the addition of a monoclonal antibody to connective tissue growth factor, pamrevlumab, to neoadjuvant chemotherapy would be safe and lead to improved resectability in this surgically adverse patient population. Methods In this phase I/II trial, 37 patients with LAPC were randomised 2:1 to gemcitabine/nab-paclitaxel plus (Arm A, n=24) or minus (Arm B, n=13) pamrevlumab. Those who completed six cycles of treatment were assessed for surgical eligibility by protocol-defined criteria. Resection rates, progression-free and overall survival were evaluated. Results Eighteen (75%) patients in Arm A and seven (54%) in Arm B completed six cycles of therapy with similar toxicity patterns. In Arms A and B, carbohydrate antigen 19–9 response, as defined by ≥50% decline from baseline, occurred in 13 (65%) and 5 (42%), respectively. Sixteen (16%) per cent of patients were radiographically downstaged by National Comprehensive Cancer Network criteria (5 in Arm A (21%) and 1 (8%) in Arm B). Positron emission tomography normalised in 9 (38%) vs 3 (23%) of patients in Arm A vs Arm B, respectively, and correlated with surgical exploration. Eligibility for surgical exploration was 17 (71%) vs 2 (15%) (p=0.0019) and resection was achieved in 8 (33%) vs 1 (8%) of patients in Arm A vs Arm B (p=0.1193), respectively. Postoperative complication rates were not different between arms. Conclusions Neoadjuvant chemotherapy with pamrevlumab holds promise for enhancing resection rates in patients with LAPC without added toxicity. This combination merits evaluation in a larger patient cohort.
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Affiliation(s)
| | - Adnan Alseidi
- Virginia Mason Medical Center, Seattle, Washington, USA
| | - Jordan Winter
- Thomas Jefferson Medical Center, Philadelphia, Pennsylvania, USA
| | | | - Kabir Mody
- Mayo Clinic Jacksonville, Jacksonville, Florida, USA
| | - John Glaspy
- UCLA Medical Center, Los Angeles, California, USA
| | - Timothy Larson
- Virginia Piper Cancer Institute, Minneapolis, Minnesota, USA
| | - Marc Matrana
- Ochsner Clinic Foundation, New Orleans, Louisiana, USA
| | - Mairead Carney
- Clinical Development, FibroGen, Inc, San Francisco, California, USA
| | - Seth Porter
- Clinical Development, FibroGen, Inc, San Francisco, California, USA
| | - Elias Kouchakji
- Clinical Development, FibroGen, Inc, San Francisco, California, USA
| | - Flavio Rocha
- Virginia Mason Medical Center, Seattle, Washington, USA
| | - Ewa Carrier
- Clinical Development, FibroGen, Inc, San Francisco, California, USA
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41
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Brada LJH, Walma MS, Daamen LA, van Roessel S, van Dam RM, de Hingh IH, Liem MLS, de Meijer VE, Patijn GA, Festen S, Stommel MWJ, Bosscha K, Polée MB, Yung Nio C, Wessels FJ, de Vries JJJ, van Lienden KP, Bruijnen RC, Los M, Mohammad NH, Wilmink HW, Busch OR, Besselink MG, Quintus Molenaar I, van Santvoort HC. Predicting overall survival and resection in patients with locally advanced pancreatic cancer treated with FOLFIRINOX: Development and internal validation of two nomograms. J Surg Oncol 2021; 124:589-597. [PMID: 34115379 DOI: 10.1002/jso.26567] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 04/07/2021] [Accepted: 05/15/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVES Patients with locally advanced pancreatic cancer (LAPC) are increasingly treated with FOLFIRINOX, resulting in improved survival and resection of tumors that were initially unresectable. It remains unclear, however, which specific patients benefit from FOLFIRINOX. Two nomograms were developed predicting overall survival (OS) and resection at the start of FOLFIRINOX for LAPC. METHODS From our multicenter, prospective LAPC registry in 14 Dutch hospitals, LAPC patients starting first-line FOLFIRINOX (April 2015-December 2017) were included. Stepwise backward selection according to the Akaike Information Criterion was used to identify independent baseline predictors for OS and resection. Two prognostic nomograms were generated. RESULTS A total of 252 patients were included, with a median OS of 14 months. Thirty-two patients (13%) underwent resection, with a median OS of 23 months. Older age, female sex, Charlson Comorbidity Index ≤1, and CA 19.9 < 274 were independent factors predicting a better OS (c-index: 0.61). WHO ps >1, involvement of the superior mesenteric artery, celiac trunk, and superior mesenteric vein ≥ 270° were independent factors decreasing the probability of resection (c-index: 0.79). CONCLUSIONS Two nomograms were developed to predict OS and resection in patients with LAPC before starting treatment with FOLFIRINOX. These nomograms could be beneficial in the shared decision-making process and counseling of these patients.
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Affiliation(s)
- Lilly J H Brada
- Department of Surgery, UMC Utrecht Cancer Center, St Antonius Hospital Nieuwegein and Meander Medical Center, Utrecht, The Netherlands.,Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marieke S Walma
- Department of Surgery, UMC Utrecht Cancer Center, St Antonius Hospital Nieuwegein and Meander Medical Center, Utrecht, The Netherlands.,Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Lois A Daamen
- Department of Surgery, UMC Utrecht Cancer Center, St Antonius Hospital Nieuwegein and Meander Medical Center, Utrecht, The Netherlands
| | - Stijn van Roessel
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ronald M van Dam
- Department of Surgery, Maastricht UMC+, Maastricht, The Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands.,Department of Epidemiology, Maastricht University, Maastricht, The Netherlands
| | - Mike L S Liem
- Department of Surgery, Medical Spectrum Twente, Enschede, The Netherlands
| | | | - Gijs A Patijn
- Department of Surgery, Isala, Zwolle, The Netherlands
| | | | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Marco B Polée
- Department of Medical Oncology, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - C Yung Nio
- Department of Radiology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Frank J Wessels
- Department of Radiology, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jan J J de Vries
- Department of Radiology, Cancer Center Amsterdam, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Krijn P van Lienden
- Department of Radiology, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Rutger C Bruijnen
- Department of Radiology, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Maartje Los
- Department of Medical Oncology, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein, Regional Academic Cancer Center Utrecht, Utrecht, The Netherlands
| | - Nadia Haj Mohammad
- Department of Medical Oncology, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein, Regional Academic Cancer Center Utrecht, Utrecht, The Netherlands
| | - Hanneke W Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, UMC Utrecht Cancer Center, St Antonius Hospital Nieuwegein and Meander Medical Center, Utrecht, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, UMC Utrecht Cancer Center, St Antonius Hospital Nieuwegein and Meander Medical Center, Utrecht, The Netherlands
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Fukahori M, Miwa K, Murotani K, Naito Y, Ushijima T, Sakaue T, Tanaka T, Nagasu S, Suga H, Kakuma T, Okabe Y, Torimura T. A phase II study of gemcitabine plus nab-paclitaxel as first-line therapy for locally advanced pancreatic cancer. Medicine (Baltimore) 2021; 100:e26052. [PMID: 34011119 PMCID: PMC8137062 DOI: 10.1097/md.0000000000026052] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 05/03/2021] [Indexed: 01/05/2023] Open
Abstract
Gemcitabine plus nab-paclitaxel (GnP) is widely used in clinical practice, despite a lack of prospective data to validate its efficacy in locally advanced pancreatic cancer (LAPC). We conducted a phase II study of GnP for LAPC to assess its efficacy and safety.We performed a single-arm, single-institution study with GnP in 24 patients with LAPC. The treatment protocol included successive administration of gemcitabine (1000 mg/m2) and nab-paclitaxel (125 mg/m2). The primary endpoint was the tumor overall response rate (ORR), and secondary endpoints were overall survival (OS), progression-free survival (PFS), and adverse events (AEs).The median PFS was 11.0 months, median OS was 21.2 months, ORR was 62.5%, and 37.5% of the patients had stable disease. Four (16.7%) of the patients were converted to surgical resection; 3 of these achieved R0 resection. Grade 3 to 4 AEs included hematological (neutropenia, 64%; thrombocytopenia, 12%), nonhematological (cholangitis, 16%), and sensory neuropathy (4%). These AEs were manageable and tolerable.The GnP treatment in patients with LAPC showed favorable tumor shrinkage, good toxicity profile, and enabled conversion to surgical resection in a subset of patients; therefore, GnP is an option for first-line chemotherapy in patients with LAPC.
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Affiliation(s)
- Masaru Fukahori
- Division of Gastroenterology, Department of Internal Medicine, Kurume University School of Medicine
- Multidisciplinary Treatment Cancer Center, Kurume University Hospital
| | - Keisuke Miwa
- Multidisciplinary Treatment Cancer Center, Kurume University Hospital
| | | | - Yoshiki Naito
- Department of Diagnostic Pathology, Kurume University Hospital, Kurume-shi
| | - Tomoyuki Ushijima
- Division of Gastroenterology, Department of Internal Medicine, Kurume University School of Medicine
- Multidisciplinary Treatment Cancer Center, Kurume University Hospital
| | - Takahiko Sakaue
- Division of Gastroenterology, Department of Internal Medicine, Kurume University School of Medicine
| | - Toshimitsu Tanaka
- Division of Gastroenterology, Department of Internal Medicine, Kurume University School of Medicine
- Multidisciplinary Treatment Cancer Center, Kurume University Hospital
| | - Sachiko Nagasu
- Multidisciplinary Treatment Cancer Center, Kurume University Hospital
| | - Hideya Suga
- Division of Gastroenterology, Yanagawa Hospital, Chikushi-machi, Yanagawa-shi, Fukuoka, Japan
| | | | - Yoshinobu Okabe
- Division of Gastroenterology, Department of Internal Medicine, Kurume University School of Medicine
| | - Takuji Torimura
- Division of Gastroenterology, Department of Internal Medicine, Kurume University School of Medicine
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Zhou Y, Liao S, You J, Wu H. Conversion surgery for initially unresectable pancreatic ductal adenocarcinoma following induction therapy: a systematic review of the published literature. Updates Surg 2021; 74:43-53. [PMID: 34021484 DOI: 10.1007/s13304-021-01089-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 05/12/2021] [Indexed: 12/18/2022]
Abstract
Patients with unresectable pancreatic ductal adenocarcinoma (UR-PDAC) are traditionally treated with palliative chemotherapy. The aim of this study was to evaluate the safety and efficacy of conversion surgery for initially UR-PDAC following induction therapy. The PubMed and Embase databases were systematically searched for eligible studies published between January 2000 and October 2020. Thirty-two series involving 1270 patients with 1056 locally advanced (LA) disease and 214 distant metastases were reviewed. The median mortality and morbidity was 0% (range 0-10%) and 47.1% (range 8.6-93.3%), respectively. Lymph-node negativity, negative resection margin and pathological complete response were observed in a median of 62.9% (38.5-90.9%), 84.4% (32.8-100%) and 6.7% (0-45.8%) of the specimens. The median survival was 32 (16.4-63.9) months with a 3-year survival rate of 47% (22-80%). Meta-analysis demonstrated that conversion surgery of initially UR-PDAC was associated with a significantly improved survival (hazard ratio [HR] = 0.55; 95% confidence intervals (CI) 0.45-0.66, P < 0.001). There was no significant difference in survival between the group with LA disease and that with distant metastases after conversion surgery (HR = 0.96; 95% CI 0.72-1.28, P = 0.790). Conversion surgery improved long-term survival of patients with initially UR-PDAC who had favorable response to induction therapy.
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Affiliation(s)
- Yanming Zhou
- Department of Hepatobiliary and Pancreatovascular Surgery, First Hospital of Xiamen University, #55 Zhenhai Road, Xiamen, 361003, China.
| | - Shan Liao
- Department of Hepatobiliary and Pancreatovascular Surgery, First Hospital of Xiamen University, #55 Zhenhai Road, Xiamen, 361003, China
| | - Jun You
- Department of Hepatobiliary and Pancreatovascular Surgery, First Hospital of Xiamen University, #55 Zhenhai Road, Xiamen, 361003, China
| | - Huaxing Wu
- Department of Hepatobiliary and Pancreatovascular Surgery, First Hospital of Xiamen University, #55 Zhenhai Road, Xiamen, 361003, China
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Wei M, Gu B, Song S, Zhang B, Wang W, Xu J, Yu X, Shi S. A Novel Validated Recurrence Stratification System Based on 18F-FDG PET/CT Radiomics to Guide Surveillance After Resection of Pancreatic Cancer. Front Oncol 2021; 11:650266. [PMID: 34055620 PMCID: PMC8149949 DOI: 10.3389/fonc.2021.650266] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 04/19/2021] [Indexed: 12/20/2022] Open
Abstract
objective Despite the heterogeneous biology of pancreatic cancer, similar surveillance schemas have been used. Identifying the high recurrence risk population and conducting prompt intervention may improve prognosis and prolong overall survival. Methods One hundred fifty-six resectable pancreatic cancer patients who had undergone 18F-FDG PET/CT from January 2013 to December 2018 were retrospectively reviewed. The patients were categorized into a training cohort (n = 109) and a validation cohort (n = 47). LIFEx software was used to extract radiomic features from PET/CT. The risk stratification system was based on predictive factors for recurrence, and the index of prediction accuracy was used to reflect both the discrimination and calibration. Results Overall, seven risk factors comprising the rad-score and clinical variables that were significantly correlated with relapse were incorporated into the final risk stratification system. The 1-year recurrence-free survival differed significantly among the low-, intermediate-, and high-risk groups (85.5, 24.0, and 9.1%, respectively; p < 0.0001). The C-index of the risk stratification system in the development cohort was 0.890 (95% CI, 0.835-0.945). Conclusion The 18F-FDG PET/CT-based radiomic features and clinicopathological factors demonstrated good performance in predicting recurrence after pancreatectomy in pancreatic cancer patients, providing a strong recommendation for an adequate adjuvant therapy course in all patients. The high-risk recurrence population should proceed with closer follow-up in a clinical setting.
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Affiliation(s)
- Miaoyan Wei
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Pancreatic Cancer Multidisciplinary Center, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China.,Pancreatic Cancer Institute, Fudan University, Shanghai, China.,Shanghai Pancreatic Cancer Institute, Shanghai, China
| | - Bingxin Gu
- Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China.,Department of Nuclear Medicine, Fudan University Shanghai Cancer Center, Shanghai, China.,Center for Biomedical Imaging, Fudan University, Shanghai, China
| | - Shaoli Song
- Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China.,Department of Nuclear Medicine, Fudan University Shanghai Cancer Center, Shanghai, China.,Center for Biomedical Imaging, Fudan University, Shanghai, China
| | - Bo Zhang
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Pancreatic Cancer Multidisciplinary Center, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China.,Pancreatic Cancer Institute, Fudan University, Shanghai, China.,Shanghai Pancreatic Cancer Institute, Shanghai, China
| | - Wei Wang
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Pancreatic Cancer Multidisciplinary Center, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China.,Pancreatic Cancer Institute, Fudan University, Shanghai, China.,Shanghai Pancreatic Cancer Institute, Shanghai, China
| | - Jin Xu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Pancreatic Cancer Multidisciplinary Center, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China.,Pancreatic Cancer Institute, Fudan University, Shanghai, China.,Shanghai Pancreatic Cancer Institute, Shanghai, China
| | - Xianjun Yu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Pancreatic Cancer Multidisciplinary Center, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China.,Pancreatic Cancer Institute, Fudan University, Shanghai, China.,Shanghai Pancreatic Cancer Institute, Shanghai, China
| | - Si Shi
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Pancreatic Cancer Multidisciplinary Center, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China.,Pancreatic Cancer Institute, Fudan University, Shanghai, China.,Shanghai Pancreatic Cancer Institute, Shanghai, China
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45
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Ahn S, Lee JC, Kim J, Kim YH, Yoon YS, Han HS, Kim H, Hwang JH. Four-Tier Pathologic Tumor Regression Grading System Predicts the Clinical Outcome in Patients Who Undergo Surgical Resection for Locally Advanced Pancreatic Cancer after Neoadjuvant Chemotherapy. Gut Liver 2021; 16:129-137. [PMID: 33875622 PMCID: PMC8761920 DOI: 10.5009/gnl20312] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 01/11/2021] [Accepted: 01/25/2021] [Indexed: 11/05/2022] Open
Abstract
Background/Aims Neoadjuvant chemotherapy is increasingly utilized in patients with borderline or locally advanced pancreatic cancer (LAPC). However, the pathologic evaluation of tumor regression is not routinely performed or well established. We aimed to evaluate the prognostic value of three tumor regression grading systems frequently used in LAPC and to determine the correlation between pathologic and clinical response. Methods We included a total of 38 patients with LAPC who were treated with neoadjuvant chemotherapy and subsequent resection. Pathologic tumor regression was graded based on the College of American Pathologists (CAP), Evans, and MD Anderson grading systems. Results One out of 38 patients (2.6%) achieved a pathologic complete response. Unlike other grading systems (Evans, p=0.063; MD Anderson, p=0.110), the CAP grading system was a significant prognostic factor for overall survival (p=0.043). Pathologic N stage (p=0.023), margin status (p=0.044), and radiologic response (p=0.016) correlated with overall survival. In the multivariate analysis, CAP 3 was an independent predictor of shorter overall survival (p=0.026). The CAP grading system correlated with the radiologic response (p=0.007) but not the carbohydrate antigen 19-9 level (p=0.333). Conclusions The four-tier CAP pathologic tumor regression grading system predicted the clinical outcome in LAPC patients who underwent resection after neoadjuvant chemotherapy. Therefore, a more comprehensive pathologic evaluation is warranted in these patients.
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Affiliation(s)
- Soomin Ahn
- Department of Pathology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jong-Chan Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jaihwan Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Young Hoon Kim
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Haeryoung Kim
- Department of Pathology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-Hyeok Hwang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Rossi G, Simoni N, Paiella S, Rossi R, Venezia M, Micera R, Malleo G, Salvia R, Giuliani T, Di Gioia A, Auriemma A, Milella M, Guariglia S, Cavedon C, Bassi C, Mazzarotto R. Risk Adapted Ablative Radiotherapy After Intensive Chemotherapy for Locally Advanced Pancreatic Cancer. Front Oncol 2021; 11:662205. [PMID: 33959509 PMCID: PMC8093383 DOI: 10.3389/fonc.2021.662205] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/16/2021] [Indexed: 01/05/2023] Open
Abstract
Background and Objective To assess the efficacy of a Risk-Adapted Ablative Radiotherapy (RAdAR) approach, after intensive induction chemotherapy, in patients with locally advanced pancreatic cancer (LAPC). Material and Methods Patients with LAPC who received RAdAR following induction chemotherapy from January 2017 to December 2019 were included in this observational study. The RAdAR approach consisted of an anatomy- and simultaneous integrated boost (SIB)-based dose prescription strategy. RAdAR was delivered with stereotactic ablative radiation therapy (SAbR), administering 30 Gy in 5 fractions to the tumor volume (PTVt) and 50 Gy SIB (BED10 100 Gy) to the vascular involvement, or with (hypo-)fractionated ablative radiotherapy (HART) prescribing 50.4 Gy in 28 fractions to the PTVt, with a vascular SIB of 78.4 Gy (BED10 100 Gy). Primary end points were freedom from local progression (FFLP), overall survival (OS), and progression-free survival (PFS). Results Sixty-four LAPC patients were included. Induction chemotherapy consisted of gemcitabine/nab-paclitaxel in 60.9% and FOLFIRINOX in 39.1% of cases. SAbR was used in 52 (81.2%) patients, and HART in 12 (18.8%). After RAdAR, surgery was performed in 17 (26.6%) patients. Median follow-up was 16.1 months. Overall local control (LC) rate was 78.1%, with no difference between resected and non-resected patients (2-year FFLP 75.3% vs 56.4%; p = 0.112). Median OS and PFS were 29.7 months and 8.7 months, respectively, for the entire cohort. Resected patients had a better median OS (not reached versus 26.1 months; p = 0.0001) and PFS (19 versus 5.6 months; p < 0.0001) compared to non-resected patients. In non-resected patients, no significant difference was found between SAbR and HART for median FFLP (28.1 versus 18.5 months; p = 0.614), OS (27.4 versus 25.3 months; p = 0.624), and PFS (5.7 versus 4.3 months; p = 0.486). One patient (1.6%) experienced acute grade 4 gastro-intestinal bleeding. No other acute or late grade ≥ 3 toxicities were observed. Conclusions The RAdAR approach, following intensive induction chemotherapy, is an effective radiation treatment strategy for selected LAPC patients, representing a promising therapeutic option in a multimodality treatment regimen.
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Affiliation(s)
- Gabriella Rossi
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Nicola Simoni
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Salvatore Paiella
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Rossi
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Martina Venezia
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Renato Micera
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Tommaso Giuliani
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Anthony Di Gioia
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Alessandra Auriemma
- Department of Oncology, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Michele Milella
- Department of Oncology, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Stefania Guariglia
- Department of Medical Physics, University of Verona Hospital Trust, Verona, Italy
| | - Carlo Cavedon
- Department of Medical Physics, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Renzo Mazzarotto
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona, Italy
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Kokumai T, Aoki S, Mizuma M, Maeda S, Ohtsuka H, Nakagawa K, Morikawa T, Motoi F, Kamei T, Unno M. Prognostic value of an inflammation-based nutritional score for patients with initially unresectable pancreatic adenocarcinoma undergoing conversion surgery following chemo-/radiotherapy. Surg Today 2021; 51:1682-1693. [PMID: 33829334 DOI: 10.1007/s00595-021-02279-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 02/07/2021] [Indexed: 12/11/2022]
Abstract
PURPOSE To clarify the prognostic value of the preoperative nutrition status of patients undergoing conversion surgery (CS) for initially unresectable pancreatic adenocarcinoma (UR-PA). METHODS The subjects of this retrospective study were 41 consecutive patients with initially UR-PA treated with chemo-/radiotherapy and subsequent CS between 2007 and 2014, at Tohoku University Hospital. The preoperative Glasgow Prognostic Score (GPS) was 0, conveying normal nutrition, in 25 patients (N group) and 1-2, conveying malnutrition, in 16 patients (M group). The clinicopathological factors influencing overall survival were defined by uni- and multivariate analyses. RESULTS The M group had a significantly worse prognosis than the N group (median overall survival (mOS) 9.6 vs 40.7 months, p = 0.001). Multivariate analysis identified a GPS of 1-2 as an independent predictor of worse prognosis [hazard ratio (HR)3.437, p = 0.032], followed by CA19-9 elevation before CS (HR4.089, p = 0.012) and pathological lymph node metastases (HR2.314, p = 0.046). Patients who maintained a favorable nutritional status (GPS 0) during preoperative treatment had a significantly better prognosis, whereas those whose nutritional status deteriorated (elevated to GPS 1-2) had poorer survival (mOS 40.7 vs. 9.7 months, p = 0.003) CONCLUSION: Preoperative malnutrition status (GPS 1-2) is considered an independent predictor of a worse prognosis for patients undergoing CS for initially UR-PA.
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Affiliation(s)
- Takashi Kokumai
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Shuichi Aoki
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan.
| | - Masamichi Mizuma
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Shimpei Maeda
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Hideo Ohtsuka
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Kei Nakagawa
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Takanori Morikawa
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Fuyuhiko Motoi
- Department of Surgery, Yamagata University Graduate School of Medical Science, Yamagata, Japan
| | - Takashi Kamei
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
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Preoperative CA19-9: a competitive predictor of recurrence in patients with colorectal cancer liver metastases after hepatectomy. Int J Colorectal Dis 2021; 36:767-778. [PMID: 33420522 DOI: 10.1007/s00384-020-03828-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/25/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE The role of preoperative carbohydrate antigen 19-9 (CA19-9) in colorectal cancer liver metastases (CRLM) patients is still unclear. The present study aimed to explore the prognostic significance of preoperative CA19-9 in those patients. METHODS A total of 691 CRLM patients were included in this study. X-tile analyses were performed to determine the optimal cut-off values of CA19-9 and carcinoembryonic antigen (CEA). Prognostic predictors were identified by multivariate analyses. RESULTS The optimal cut-off values of CA19-9 and CEA for 5-year recurrence-free survival (RFS) were 35.24 U/ml and 20.4 ng/ml, respectively. Patients with high-level CA19-9 had significantly worse RFS and overall survival (OS) than those with low-level CA19-9 (P = 0.001 and P = 0.002, respectively). In addition, patients with high-level CA19-9 had poor RFS and OS (P = 0.028 and P = 0.011, respectively) at low-level CEA. Multivariate analyses confirmed that preoperative CA19-9 was an independent predictor for RFS (hazard ratio [HR] 1.295; 95% confidence interval [CI] 1.043-1.607; P = 0.019) but not for OS (HR 1.213; 95% CI 0.902-1.631; P = 0.201). CONCLUSION CA19-9 is a promising predictor of recurrence for CRLM patients undergoing hepatectomy, and an effective supplement for patients with low-level CEA.
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González-Gómez R, Pazo-Cid RA, Sarría L, Morcillo MÁ, Schuhmacher AJ. Diagnosis of Pancreatic Ductal Adenocarcinoma by Immuno-Positron Emission Tomography. J Clin Med 2021; 10:1151. [PMID: 33801810 PMCID: PMC8000738 DOI: 10.3390/jcm10061151] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 02/26/2021] [Accepted: 03/02/2021] [Indexed: 12/15/2022] Open
Abstract
Diagnosis of pancreatic ductal adenocarcinoma (PDAC) by current imaging techniques is useful and widely used in the clinic but presents several limitations and challenges, especially in small lesions that frequently cause radiological tumors infra-staging, false-positive diagnosis of metastatic tumor recurrence, and common occult micro-metastatic disease. The revolution in cancer multi-"omics" and bioinformatics has uncovered clinically relevant alterations in PDAC that still need to be integrated into patients' clinical management, urging the development of non-invasive imaging techniques against principal biomarkers to assess and incorporate this information into the clinical practice. "Immuno-PET" merges the high target selectivity and specificity of antibodies and engineered fragments toward a given tumor cell surface marker with the high spatial resolution, sensitivity, and quantitative capabilities of positron emission tomography (PET) imaging techniques. In this review, we detail and provide examples of the clinical limitations of current imaging techniques for diagnosing PDAC. Furthermore, we define the different components of immuno-PET and summarize the existing applications of this technique in PDAC. The development of novel immuno-PET methods will make it possible to conduct the non-invasive diagnosis and monitoring of patients over time using in vivo, integrated, quantifiable, 3D, whole body immunohistochemistry working like a "virtual biopsy".
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Affiliation(s)
- Ruth González-Gómez
- Molecular Oncology Group, Instituto de Investigación Sanitaria Aragón (IIS Aragón), 50009 Zaragoza, Spain;
| | - Roberto A. Pazo-Cid
- Medical Oncology Unit, Hospital Universitario Miguel Servet, 50009 Zaragoza, Spain;
| | - Luis Sarría
- Digestive Radiology Unit, Hospital Universitario Miguel Servet, 50009 Zaragoza, Spain;
| | - Miguel Ángel Morcillo
- Biomedical Application of Radioisotopes and Pharmacokinetics Unit, Centro de Investigaciones Energéticas, Medioambientales y Tecnológicas (CIEMAT), 28040 Madrid, Spain
| | - Alberto J. Schuhmacher
- Molecular Oncology Group, Instituto de Investigación Sanitaria Aragón (IIS Aragón), 50009 Zaragoza, Spain;
- Fundación Aragonesa para la Investigación y el Desarrollo (ARAID), 50018 Zaragoza, Spain
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Kato H, Horiguchi A, Ito M, Asano Y, Arakawa S. Essential updates 2019/2020: Multimodal treatment of localized pancreatic adenocarcinoma: Current topics and updates in survival outcomes and prognostic factors. Ann Gastroenterol Surg 2021; 5:132-151. [PMID: 33860134 PMCID: PMC8034700 DOI: 10.1002/ags3.12427] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 11/26/2020] [Accepted: 12/22/2020] [Indexed: 12/13/2022] Open
Abstract
Overall survival of patients with localized pancreatic ductal adenocarcinoma (PDAC) is extremely poor. Therefore, the establishment of multimodal treatment strategies is indispensable for PDAC patients because surgical treatment alone could not contribute to the improvement of survival. In this review article, we focus on the current topics and advancement of the treatments for localized PDAC including resectable, borderline resectable, and locally advanced PDAC in accordance with the articles mainly published from 2019 to 2020. Reviewing the articles, the recent progress of multimodal treatments notably improves the prognosis of patients with localized PDAC. For resectable PDAC, neoadjuvant chemo or chemoradiation therapy, rather than upfront surgery, plays a key role, especially in patients with a large tumor, poor performance status, high tumor marker levels, peripancreatic lymph nodes metastasis, or neural invasion suspected on preoperative imaging. For borderline resectable PDAC, neoadjuvant treatments followed by surgery is a desirable approach, and maintenance of immunonutritional status during the treatments are also important. For locally advanced disease, conversion surgery has a central role in improving a survival outcome; however, its indication should be standardized.
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Affiliation(s)
- Hiroyuki Kato
- Department of Gastroenterological SurgeryBantane HospitalFujita Health University School of MedicineNagoyaAichiJapan
| | - Akihiko Horiguchi
- Department of Gastroenterological SurgeryBantane HospitalFujita Health University School of MedicineNagoyaAichiJapan
| | - Masahiro Ito
- Department of Gastroenterological SurgeryBantane HospitalFujita Health University School of MedicineNagoyaAichiJapan
| | - Yukio Asano
- Department of Gastroenterological SurgeryBantane HospitalFujita Health University School of MedicineNagoyaAichiJapan
| | - Satoshi Arakawa
- Department of Gastroenterological SurgeryBantane HospitalFujita Health University School of MedicineNagoyaAichiJapan
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