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Gorbudhun R, Patel PH, Hopping E, Doyle J, Geropoulos G, Mavroeidis VK, Kumar S, Bhogal RH. Neoadjuvant Chemotherapy-Chemoradiation for Borderline-Resectable Pancreatic Adenocarcinoma: A UK Tertiary Surgical Oncology Centre Series. Cancers (Basel) 2022; 14:cancers14194678. [PMID: 36230600 PMCID: PMC9563387 DOI: 10.3390/cancers14194678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 09/13/2022] [Accepted: 09/19/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Patients with borderline-resectable pancreatic ductal adenocarcinoma (BR-PDAC) have historically poor survival, even after curative pancreatic resection and adjuvant chemotherapy. Emerging evidence suggests that neoadjuvant chemoradiation (NCR) improves R0 resection rates in BR-PDAC patients. We evaluated the R0 resection rate, disease-free survival (DFS) and overall survival (OS) in our patients who underwent NCR for BR-PDAC at our institution. Methods: All patients who underwent NCR for BR-PDAC from January 2010 to March 2020 were included in the study. The patients received a variety of NCR regimens during the study period, and in patients with radiological evidence of tumour stability or regression, pancreatic resection was performed. The primary endpoint was the OS, and the secondary endpoints included patient morbidity, the R0 resection rate, histological parameters and the DFS. Results: The study included 29 patients (16 men and 13 women), with a median age of 65 years (range 46–74 years). Of these 29 patients, 17 received FOLFIRINOX and 12 received gemcitabine (GEM)-based NCR regimens. All patients received chemoradiation at the end of chemotherapy (range 45–56 Gy). R0 resection was achieved in 75% of the patients, with a higher rate noted in the FOLFIRINOX group. The median DFS was 22 months for the whole cohort but higher in the FOLFIRINOX group (34 months). The median OS for the cohort was 29 months, with a higher median OS noted for the FOLFIRINOX cohort versus the GEM cohort (42 versus 28 months). Conclusion: NCR, particularly FOLFIRINOX-based treatment, for BR-PDAC results in higher rates of R0 resection and an increased median DFS and OS, supporting its continued use in this patient group.
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Affiliation(s)
- Rachna Gorbudhun
- Department of Surgery, The Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK
| | - Pranav H. Patel
- Department of Surgery, The Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK
| | - Eve Hopping
- Department of Surgery, The Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK
| | - Joseph Doyle
- Department of Surgery, The Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK
| | - Georgios Geropoulos
- Department of Surgery, The Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK
| | | | - Sacheen Kumar
- Department of Surgery, The Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK
- Upper Gastrointestinal Research Group, Department of Radiotherapy, Institute of Cancer Research, 123 Old Brompton Road, London SW7 3RP, UK
| | - Ricky H. Bhogal
- Department of Surgery, The Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK
- Upper Gastrointestinal Research Group, Department of Radiotherapy, Institute of Cancer Research, 123 Old Brompton Road, London SW7 3RP, UK
- Correspondence: ; Tel.: +44-0208-7808-2781
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Kelliher LJS, Krige A. Anaesthesia for Pancreatic Surgery. Anesthesiol Clin 2022; 40:107-117. [PMID: 35236575 DOI: 10.1016/j.anclin.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
This article provides a broad perspective on the salient perioperative issues encountered when caring for patients undergoing pancreatic surgery in the setting of pancreatic cancer. It describes the epidemiology of pancreatic cancer, the indications for and evolution of pancreatic resection surgery, the challenges faced perioperatively including patient selection, optimization, anesthetic considerations, postoperative analgesia, fluid management, and nutrition and discusses some of the common complications and their management. It finishes by outlining the future directions for research and development required to continue improving outcomes for these patients.
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Affiliation(s)
- Leigh J S Kelliher
- Department of Anaesthetics, Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford, Surrey, GU2 7AS, UK.
| | - Anton Krige
- Department of Anaesthesia and Critical Care, Royal Blackburn Teaching Hospital, Haslingden Road, Blackburn BB2 3HH, UK
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Wang J, Liu X, Hu B, Gao Y, Chen J, Li J. Development and validation of an MRI-based radiomic nomogram to distinguish between good and poor responders in patients with locally advanced rectal cancer undergoing neoadjuvant chemoradiotherapy. Abdom Radiol (NY) 2021; 46:1805-1815. [PMID: 33151359 DOI: 10.1007/s00261-020-02846-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 10/25/2020] [Accepted: 10/29/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE In the clinical management of patients with locally advanced rectal cancer (LARC), the early identification of poor and good responders after neoadjuvant chemoradiotherapy (N-CRT) is essential. Therefore, we developed and validated predictive models including MRI findings from the structured report template, clinical and radiomics parameters to differentiate between poor and good responders in patients with locally advanced rectal cancer who underwent neoadjuvant chemoradiotherapy. METHODS Preoperative multiparametric MRI from 183 patients with locally advanced rectal cancer (122 in the training cohort, 61 in the validation cohort) was included in this retrospective study. After preprocessing, radiomic features were extracted and two methods of feature selection was applied to reduce the number of radiomics features. Logistic regression (LR) and random forest (RF) machine learning classifiers were trained to identify good responders from poor responders. Multivariable logistic regression analysis was used to incorporate the radiomic signature and clinical risk factors into a nomogram. Classifier performance was evaluated using the area under the curve (AUC), accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS For the differentiation of poor and good responders, the radiomics model with an LR classifier achieved AUCs of 0.869 and 0.842 for the training and validation cohorts, respectively. The nomogram showed the highest reproducibility and prognostic ability in the training and validation cohorts, with AUCs of 0.923 (95% confidence interval, 0.872-0.975) and 0.898 (0.819-0.978), respectively. Additionally, the nomogram achieved significant risk stratification of patients in respect to progression free survival (PFS). CONCLUSIONS The nomogram accurately differentiated good and poor responders in patients with LARC undergoing N-CRT, and showed significant performance for predicting PFS.
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Affiliation(s)
- Jia Wang
- Department of Ultrasound, Qingdao Women and Children Hospital, Qingdao, Shandong, China
| | - Xuejun Liu
- Department of Radiology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, Shandong, China
| | - Bin Hu
- Department of Radiology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, Shandong, China
| | - Yuanxiang Gao
- Department of Radiology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, Shandong, China
| | - Jingjing Chen
- Department of Radiology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, Shandong, China
| | - Jie Li
- Department of Radiology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, Shandong, China.
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Endo Y, Kitago M, Aiura K, Shinoda M, Yagi H, Abe Y, Oshima G, Hori S, Nakano Y, Itano O, Fukada J, Masugi Y, Kitagawa Y. Efficacy and safety of preoperative 5-fluorouracil, cisplatin, and mitomycin C in combination with radiotherapy in patients with resectable and borderline resectable pancreatic cancer: a long-term follow-up study. World J Surg Oncol 2019; 17:145. [PMID: 31420046 PMCID: PMC6697960 DOI: 10.1186/s12957-019-1687-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 08/06/2019] [Indexed: 12/15/2022] Open
Abstract
Background We aimed to evaluate the efficacy and safety of 5-fluorouracil-based neoadjuvant chemoradiotherapy (NACRT) in patients with resectable/borderline resectable pancreatic ductal adenocarcinoma (PDAC). Methods This retrospective study investigated the clinicopathological features and > 5-year survival of patients with T3/T4 PDAC who underwent NACRT at our institute between 2003 and 2012. Results Seventeen resectable and eight borderline resectable patients were included. The protocol treatment completion and resection rates were 92.0% and 68.0%, respectively. Two patients failed to complete chemotherapy owing to cholangitis or anorexia. Common grade 3 toxicities included anorexia (12%), neutropenia (4%), thrombocytopenia (4%), anemia (4%), and leukopenia (12%). Pathologically negative margins were achieved in 94.1% of patients who underwent pancreatectomy. Pathological response according to Evans’ classification was grade IIA in 10 patients (58.8%), IIB in 5 patients (29.4%), and IV in 2 patients (11.8%). Postoperative pancreatic fistulas were observed in four patients (23.5%), delayed gastric emptying in one patient (5.9%), and other operative morbidities in four patients (23.5%). The 1-, 2-, 5-, and 10-year overall survival rates were 73.9%, 60.9%, 60.9%, and 39.1%, respectively (median follow-up period, 80.3 months). Conclusions NACRT is tolerable and beneficial for resectable/borderline resectable PDAC, even in the long-term.
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Affiliation(s)
- Yutaka Endo
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Minoru Kitago
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan.
| | - Koichi Aiura
- Department of Surgery, Kawasaki City Hospital, Kanagawa, Japan
| | - Masahiro Shinoda
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Hiroshi Yagi
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Yuta Abe
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Go Oshima
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Shutaro Hori
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Yutaka Nakano
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Osamu Itano
- Department of Gastrointestinal Surgery, International University of Health and Welfare, Chiba, Japan
| | - Junichi Fukada
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Yohei Masugi
- Department of Pathology, Keio University School of Medicine, Tokyo, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
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Shen P, Huang KJ, Zhang CZ, Xiao L, Zhang T. Surgery with adjuvant or neoadjuvant treatment vs surgery alone for resectable pancreatic cancer: A network meta-analysis. World J Meta-Anal 2019; 7:309-322. [DOI: 10.13105/wjma.v7.i6.309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 06/04/2019] [Accepted: 06/10/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pancreatic cancer is one of the most common and lethal malignancies worldwide. The common treatment options for resectable pancreatic cancer include surgery alone, neoadjuvant chemotherapy (CT), neoadjuvant chemoradiotherapy (CRT), adjuvant CT, and adjuvant CRT. However, the optimal treatment is still controversial.
AIM To identify the most effective approach for pancreatic cancer using network meta-analysis.
METHODS Eligible studies were searched from PubMed, MEDLINE, EMBASE, Cochrane database, and Google scholar. We searched and included randomized controlled trials reporting on neoadjuvant and adjuvant therapies. For direct comparisons, standard pairwise meta-analysis was performed using the inverse variance DerSimonian-Laird random-effects model. For indirect comparisons, Bayesian network meta-analysis was used to combine direct and indirect evidence. We used relative hazard ratios (HRs) to estimate death difference of different treatments, and relative odds ratios (ORs) for toxic effects. Treatment effects were ranked based on their efficacy for improving survival or reducing toxicity using rankogram. The quality of evidence of estimates from direct comparison and network meta-analysis was evaluated following the GRADE approach.
RESULTS We included 13 high quality trials with 1591 participants in this network meta-analysis. Compared with surgery alone [pooled HR = 0.7, 95% confidence interval (CI): 0.62-0.79] and surgery with adjuvant CRT (pooled HR = 0.6, 95%CI: 0.54-0.72), surgery with adjuvant CT had a higher rate of overall survival. In contrast, standard pairwise meta-analysis showed a statistically significant survival advantage of surgery with adjuvant CT compared with surgery alone (pooled HR = 0.75, 95%CI: 0.63-0.89; P < 0.001). Rankogram showed that surgery with adjuvant CT was most likely to rank the best in terms of overall survival (probability: 94.2%), followed by surgery alone (probability: 5.8%). No significant differences in overall toxicity or haematological toxicity were found between all the therapies. High quality evidence supported surgery with adjuvant CT over surgery alone for increasing overall survival. Moderate quality evidence supported surgery with adjuvant CT over surgery with adjuvant CRT for increasing overall survival.
CONCLUSION Surgery with adjuvant CT prolongs overall survival compared with surgery alone and surgery with adjuvant CRT, suggesting surgery with adjuvant CT is the optimal treatment for resectable pancreatic cancer.
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Affiliation(s)
- Pu Shen
- Department of Anesthesia, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, Guangdong Province, China
| | - Kai-Jun Huang
- Department of General Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong Province, China
| | - Chuan-Zhao Zhang
- Department of General Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong Province, China
| | - Li Xiao
- Department of Anesthesia, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, Guangdong Province, China
| | - Tao Zhang
- Department of Anesthesia, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, Guangdong Province, China
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Long-term outcome following neoadjuvant therapy for resectable and borderline resectable pancreatic cancer compared to upfront surgery: a meta-analysis of comparative studies by intention-to-treat analysis. Surg Today 2019; 49:295-299. [PMID: 30877550 DOI: 10.1007/s00595-019-01786-w] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 02/17/2019] [Indexed: 02/07/2023]
Abstract
The aim of the study was to evaluate the effect of neoadjuvant therapy on long-term survival in patients with resectable and borderline resectable pancreatic cancer. A meta-analysis was conducted using the reported randomized, controlled trials and retrospective studies using an intention-to-treat analysis to compare upfront surgery and neoadjuvant therapy in resectable or borderline resectable pancreatic cancer patients. Six comparative studies consisting of two randomized, controlled trials and four retrospective studies were included. The overall pooled hazard ratio was 0.66 (95% confidence interval: 0.50-0.87, P = 0.003), indicating that patients in the neoadjuvant group had better long-term survival than those in the upfront surgery group. However, considerable inter-study heterogeneity was observed (I2 = 62%). This meta-analysis focusing on comparative studies analyzed by intention-to-treat analysis showed that neoadjuvant therapy for resectable and borderline resectable pancreatic cancer tends to improve patients' long-term outcomes. However, the evidence level remains too low for a firm conclusion. The well-designed, randomized, controlled trials now ongoing will provide the definite evidence needed in the future.
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