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Karamitopoulou E, Wenning AS, Acharjee A, Zlobec I, Aeschbacher P, Perren A, Gloor B. Spatially restricted tumour-associated and host-associated immune drivers correlate with the recurrence sites of pancreatic cancer. Gut 2023; 72:1523-1533. [PMID: 36792355 DOI: 10.1136/gutjnl-2022-329371] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 02/06/2023] [Indexed: 02/17/2023]
Abstract
OBJECTIVE Most patients with pancreatic ductal adenocarcinoma (PDAC) will experience recurrence after resection. Here, we investigate spatially organised immune determinants of PDAC recurrence. DESIGN PDACs (n=284; discovery cohort) were classified according to recurrence site as liver (n=93/33%), lung (n=49/17%), local (n=31/11%), peritoneal (n=38/13%) and no-recurrence (n=73/26%). Spatial compartments were identified by fluorescent imaging as: pancytokeratin (PanCK)+CD45- (tumour cells); CD45+PanCK- (leucocytes) and PanCK-CD45- (stromal cells), followed by transcriptomic (72 genes) and proteomic analysis (51 proteins) for immune pathway targets. Results from next-generation sequencing (n=194) were integrated. Finally, 10 tumours from each group underwent immunophenotypic analysis by multiplex immunofluorescence. A validation cohort (n=109) was examined in parallel. RESULTS No-recurrent PDACs show high immunogenicity, adaptive immune responses and are rich in pro-inflammatory chemokines, granzyme B and alpha-smooth muscle actin+ fibroblasts. PDACs with liver and/or peritoneal recurrences display low immunogenicity, stemness phenotype and innate immune responses, whereas those with peritoneal metastases are additionally rich in FAP+ fibroblasts. PDACs with local and/or lung recurrences display interferon-gamma signalling and mixed adaptive and innate immune responses, but with different leading immune cell population. Tumours with local recurrences overexpress dendritic cell markers whereas those with lung recurrences neutrophilic markers. Except the exclusive presence of RNF43 mutations in the no-recurrence group, no genetic differences were seen. The no-recurrence group exhibited the best, whereas liver and peritoneal recurrences the poorest prognosis. CONCLUSIONS Our findings demonstrate distinct inflammatory/stromal responses in each recurrence group, which might affect dissemination patterns and patient outcomes. These findings may help to inform personalised adjuvant/neoadjuvant and surveillance strategies in PDAC, including immunotherapeutic modalities.
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Affiliation(s)
- Eva Karamitopoulou
- Institute for Tissue Medicine and Pathology, University of Bern, Bern, Switzerland
| | - Anna Silvia Wenning
- Department of Visceral Surgery, Insel University Hospital, University of Bern, Bern, Switzerland
| | - Animesh Acharjee
- University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Inti Zlobec
- Institute for Tissue Medicine and Pathology, University of Bern, Bern, Switzerland
| | - Pauline Aeschbacher
- Department of Visceral Surgery, Insel University Hospital, University of Bern, Bern, Switzerland
| | - Aurel Perren
- Institute for Tissue Medicine and Pathology, University of Bern, Bern, Switzerland
| | - Beat Gloor
- Department of Visceral Surgery, Insel University Hospital, University of Bern, Bern, Switzerland
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2
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Zhou W, Wang D, Lou W. Current Role of Surgery in Pancreatic Cancer With Synchronous Liver Metastasis. Cancer Control 2021; 27:1073274820976593. [PMID: 33238715 PMCID: PMC7791445 DOI: 10.1177/1073274820976593] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Pancreatic cancer with synchronous liver metastasis has an extremely poor
prognosis, and surgery is not recommended for such patients by the current
guidelines. However, an increasing body of studies have shown that concurrent
resection of pancreatic cancer and liver metastasis is not only technically
feasible but also beneficial to the survival in the selected patients. In this
review, we aim to summarize the short- and long-term outcomes following
synchronous liver metastasectomy for pancreatic cancer patients, and discuss the
potential criteria in selecting appropriate surgical candidates, which might be
helpful in clinical decision-making.
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Affiliation(s)
- Wentao Zhou
- Department of Pancreatic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.,The Research Institution of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Dansong Wang
- The Research Institution of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wenhui Lou
- Department of Pancreatic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
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3
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Zhou W, Han X, Fang Y, Han S, Cai Y, Kuang T, Lou W, Wang D. Clinical Analysis of Acinar Cell Carcinoma of the Pancreas: A Single-Center Experience of 45 Consecutive Cases. Cancer Control 2021; 27:1073274820969447. [PMID: 33121259 PMCID: PMC7791459 DOI: 10.1177/1073274820969447] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Backgrounds: Acinar cell carcinoma of the pancreas is a rare malignancy, and its features
remain unclear. We aimed to analyze the clinical characteristics, treatment
and prognosis of acinar cell carcinoma with our institutional case
series. Methods: Patients diagnosed with acinar cell carcinoma in our hospital between 2005
and 2019 were reviewed. Investigations on clinicopathological features,
treatment details and long-term survival were performed. Results: A total of 45 pathologically confirmed acinar cell carcinomas were
identified. The median age at diagnosis was 58 years with a male-to-female
ratio of 3.1:1. There were 24 (53.3%) localized, 5 (11.1%) locally advanced
and 16 (35.6%) metastatic cases, with a pancreatic head-to-body/tail ratio
of 1:1.4 for all the primary lesions. In the localized group, there were 10
pancreatoduodenectomy, 12 distal pancreatectomy, 1 total pancreatectomy, and
1 distal pancreatectomy combined with proximal gastrectomy. Among the
locally advanced and metastatic cases, 13 patients received chemotherapy, 1
received concurrent radiochemotherapy, 1 underwent synchronous resection of
primary tumor and liver metastasis, 1 underwent palliative operation, 1
underwent exploratory laparotomy, and 4 required no treatment. The median
overall survival of this series was 18.9 months with a 5-year survival rate
of 19.6%. Moreover, the resected acinar cell carcinoma patients were
associated with prolonged survival compared with the unresected cases (36.6
vs. 8.5 months, P < 0.001). Conclusions: Surgical resection could improve the long-term survival of acinar cell
carcinoma patients, which might also improve the prognosis of selected
metastatic cases. Large-scale studies are needed to further clarify the
biological behavior and clinical features, and to seek the optimal
treatments.
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Affiliation(s)
- Wentao Zhou
- The Research Institution of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.,Department of Pancreatic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xu Han
- Department of Pancreatic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yuan Fang
- Department of Pancreatic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Siyang Han
- The Research Institution of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yumeng Cai
- Department of Pathology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tiantao Kuang
- The Research Institution of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wenhui Lou
- Department of Pancreatic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Dansong Wang
- The Research Institution of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
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4
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Hanada Y, Pereira SP, Pogue B, Maytin EV, Hasan T, Linn B, Mangels-Dick T, Wang KK. EUS-guided verteporfin photodynamic therapy for pancreatic cancer. Gastrointest Endosc 2021; 94:179-186. [PMID: 33647286 PMCID: PMC10434704 DOI: 10.1016/j.gie.2021.02.027] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 02/18/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Locally advanced pancreatic cancer (LAPC) often causes obstruction. Verteporfin photodynamic therapy (PDT) can feasibly "debulk" the tumor more safely than noncurative surgery and has multiple advantages over older PDT agents. We aimed to assess the feasibility of EUS-guided verteporfin PDT in ablating nonresectable LAPC. METHODS Adults with LAPC with adequate biliary drainage were prospectively enrolled. Exclusion criteria were significant metastatic disease burden, disease involving >50% duodenal or major artery circumference, and recent treatment with curative intent. CT was obtained between days -28 to 0. On day 0, verteporfin .4 mg/kg was infused 60 to 90 minutes before EUS, during which a diffuser was positioned in the tumor and delivered light at 50 J/cm for 333 seconds. CT was obtained on day 2, with adverse event monitoring occurring on days 1, 2, and 14. The primary outcome was presence of necrosis. RESULTS Of 8 patients (62.5% men, mean age 65 ± 7.9 years) included in the study, 5 were staged at T3, 2 at T2, and 1 at T1. Most (n = 4) had primary lesions in the pancreatic head. Mean pretrial tumor diameter was 33.3 ± 13.4 mm. On day 2 CT, 5 lesions demonstrated a zone of necrosis measuring a mean diameter of 15.7 ± 5.5 mm; 3 cases did not develop necrosis. No adverse events were noted during the procedure or postprocedure observation period (days 1-3), and no changes in patient-reported outcomes were noted. CONCLUSIONS In this pilot study, EUS-guided verteporfin PDT is feasible and shows promise as a minimally invasive ablative therapy for LAPC in select patients. Tumor necrosis is visible within 48 hours after treatment. Patient enrollment and data collection are ongoing. (Clinical trial registration number: NCT03033225.).
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Affiliation(s)
- Yuri Hanada
- Division of Gastroenterology and Hepatology, Mayo Clinic (Rochester, MN, USA)
| | - Stephen P. Pereira
- Institute for Liver and Digestive Health, University College London (London, England)
| | - Brian Pogue
- Department of Engineering Sciences, Dartmouth College (Hanover, NH, USA)
| | | | - Tayyaba Hasan
- Wellman Center for Photomedicine, Massachusetts General Hospital (Boston, MA, USA)
| | - Bryan Linn
- Division of Gastroenterology and Hepatology, Mayo Clinic (Rochester, MN, USA)
| | | | - Kenneth K. Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic (Rochester, MN, USA)
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5
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Timmer FEF, Geboers B, Nieuwenhuizen S, Schouten EAC, Dijkstra M, de Vries JJJ, van den Tol MP, Meijerink MR, Scheffer HJ. Locoregional Treatment of Metastatic Pancreatic Cancer Utilizing Resection, Ablation and Embolization: A Systematic Review. Cancers (Basel) 2021; 13:cancers13071608. [PMID: 33807220 PMCID: PMC8036519 DOI: 10.3390/cancers13071608] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/20/2021] [Accepted: 03/25/2021] [Indexed: 02/07/2023] Open
Abstract
Simple Summary Metastatic pancreatic ductal adenocarcinoma (mPDAC) has a dismal prognosis. In selected patients with limited metastatic disease, locoregional therapy, in addition to systemic chemotherapy, may improve survival. This systematic review sought to examine current evidence on the value of additional locoregional treatment, including resection, ablation and embolization, in patients with hepatic or pulmonary mPDAC. The results, although liable to substantial bias, demonstrated superior survival from metastatic diagnosis or treatment in a subset of patients after radical-intent local primary and metastatic treatment (hepatic mPDAC 7.8–19 months; pulmonary mPDAC 22.8–47 months) compared to chemotherapy or best supportive care (hepatic mPDAC 4.3–7.6 months; pulmonary mPDAC 11.8 months). However, as a consequence of the bias, definitive conclusions regarding the seemingly beneficial effect of locoregional treatment cannot be endorsed. Randomized controlled trials with strictly selected oligometastatic PDAC patients are required to deduce final recommendations on this notion. Abstract The prognosis of metastatic pancreatic ductal adenocarcinoma (mPDAC) remains universally poor, requiring new and innovative treatment approaches. In a subset of oligometastatic PDAC patients, locoregional therapy, in addition to systemic chemotherapy, may improve survival. The aim of this systematic review was to explore and evaluate the current evidence on locoregional treatments for mPDAC. A systematic literature search was conducted on locoregional techniques, including resection, ablation and embolization, for mPDAC with a focus on hepatic and pulmonary metastases. A total of 59 studies were identified, including 63,453 patients. Although subject to significant bias, radical-intent local therapy for both the primary and metastatic sites was associated with a superior median overall survival from metastatic diagnosis or treatment (hepatic mPDAC 7.8–19 months; pulmonary mPDAC 22.8–47 months) compared to control groups receiving chemotherapy or best supportive care (hepatic mPDAC 4.3–7.6 months; pulmonary mPDAC 11.8 months). To recruit patients that may benefit from these local treatments, selection appears essential. Most significant is the upfront possibility of local radical pancreatic and metastatic treatment. In addition, a patient’s response to neoadjuvant systemic chemotherapy, performance status, metastatic disease load and, to a lesser degree, histological differentiation grade and tumor marker CA19-9 serum levels, are powerful prognostic factors that help identify eligible subjects. Although the exact additive value of locoregional treatments for mPDAC patients cannot be distillated from the results, locoregional primary pancreatic and metastatic treatment seems beneficial for a highly selected group of oligometastatic PDAC patients. For definite recommendations, well-designed prospective randomized controlled trials with strict in- and exclusion criteria are needed to validate these results.
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Affiliation(s)
- Florentine E. F. Timmer
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (Location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands; (B.G.); (S.N.); (E.A.C.S.); (M.D.); (J.J.J.d.V.); (M.R.M.); (H.J.S.)
- Correspondence: ; Tel.: +31-20-444-4571
| | - Bart Geboers
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (Location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands; (B.G.); (S.N.); (E.A.C.S.); (M.D.); (J.J.J.d.V.); (M.R.M.); (H.J.S.)
| | - Sanne Nieuwenhuizen
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (Location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands; (B.G.); (S.N.); (E.A.C.S.); (M.D.); (J.J.J.d.V.); (M.R.M.); (H.J.S.)
| | - Evelien A. C. Schouten
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (Location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands; (B.G.); (S.N.); (E.A.C.S.); (M.D.); (J.J.J.d.V.); (M.R.M.); (H.J.S.)
| | - Madelon Dijkstra
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (Location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands; (B.G.); (S.N.); (E.A.C.S.); (M.D.); (J.J.J.d.V.); (M.R.M.); (H.J.S.)
| | - Jan J. J. de Vries
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (Location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands; (B.G.); (S.N.); (E.A.C.S.); (M.D.); (J.J.J.d.V.); (M.R.M.); (H.J.S.)
| | - M. Petrousjka van den Tol
- Department of Surgery, Amsterdam University Medical Centers (Location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands;
| | - Martijn R. Meijerink
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (Location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands; (B.G.); (S.N.); (E.A.C.S.); (M.D.); (J.J.J.d.V.); (M.R.M.); (H.J.S.)
| | - Hester J. Scheffer
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (Location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands; (B.G.); (S.N.); (E.A.C.S.); (M.D.); (J.J.J.d.V.); (M.R.M.); (H.J.S.)
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Karamitopoulou E, Esposito I, Zlobec I, Insilla AC, Wartenberg M, Schaeffer DF, Kalloger S, La Rosa S, Sempoux C, Ramos Centeno I, Lohneis P. Reproducibility of tumor budding assessment in pancreatic cancer based on a multicenter interobserver study. Virchows Arch 2020; 478:719-726. [PMID: 33330964 PMCID: PMC7990816 DOI: 10.1007/s00428-020-02987-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 11/02/2020] [Accepted: 12/03/2020] [Indexed: 02/06/2023]
Abstract
Tumor budding has been reported to be an independent prognostic factor in pancreatic ductal adenocarcinoma (PDAC). Its use in daily diagnostics would improve the prognostic stratification of patients. We performed a multicenter interobserver study to test various budding assessment methods for their reproducibility. Two serial sections of 50 resected, treatment-naïve PDACs were stained for Hematoxylin and Eosin (H&E) and pancytokeratin. Tumor budding was scored by independent observers at five participating centers in Switzerland, Germany, and Canada. Pathologists assessed tumor budding on a digital platform comparing H&E with pancytokeratin staining in 10 high-power fields (10HPF) and one HPF hotspot (1HPF). Additionally, tumor budding was assessed in one H&E hotspot at × 20 magnification, as suggested by the International Tumor Budding Consensus Conference (ITBCC). Correlation coefficients for bud counts between centers ranged from r = 0.58648 to r = 0.78641 for H&E and from r = 0.69288 to r = 0.81764 for pancytokeratin. The highest interobserver agreement across all centers was observed for pancytokeratin 10HPFs (ICC = 0.6). ICC values were 0.49, 0.48, 0.41, and 0.4 for H&E in 1HPF hotspot, H&E in 10HPFs, pancytokeratin in 1HPF, and H&E in one hotspot at ×20, respectively (ITBCC method). This interobserver study reveals a range between moderately poor to moderate agreement levels between pathologists for the different tumor budding assessment methods in PDAC. Acceptable levels of agreement were reached with the pancytokeratin 10HPF method, which can thus be recommended for the assessment of tumor budding in PDAC resection specimens. To improve the levels of interobserver agreement, the implementation of machine learning applications should be considered.
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Affiliation(s)
- Eva Karamitopoulou
- Pancreatic Cancer Research Group, Institute of Pathology, University of Bern, Bern, Switzerland.
| | - Irene Esposito
- Institute of Pathology Heinrich-Heine University & University Hospital, Duesseldorf, Germany
| | - Inti Zlobec
- Pancreatic Cancer Research Group, Institute of Pathology, University of Bern, Bern, Switzerland
| | - Andrea Cacciato Insilla
- Institute of Pathology Heinrich-Heine University & University Hospital, Duesseldorf, Germany
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Martin Wartenberg
- Pancreatic Cancer Research Group, Institute of Pathology, University of Bern, Bern, Switzerland
| | - David F Schaeffer
- Department of Pathology & Laboratory Medicine, University of British Columbia and Division of Anatomic Pathology, Vancouver General Hospital, Vancouver, Canada
| | - Steve Kalloger
- Department of Pathology & Laboratory Medicine, University of British Columbia and Division of Anatomic Pathology, Vancouver General Hospital, Vancouver, Canada
| | - Stefano La Rosa
- Institute of Pathology, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Christine Sempoux
- Institute of Pathology, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Irene Ramos Centeno
- Pancreatic Cancer Research Group, Institute of Pathology, University of Bern, Bern, Switzerland
| | - Philipp Lohneis
- Faculty of Medicine and University Hospital Cologne, Institute of Pathology, University of Cologne, Cologne, Germany
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The Tumor Microenvironment of Pancreatic Cancer. Cancers (Basel) 2020; 12:cancers12103076. [PMID: 33096881 PMCID: PMC7589160 DOI: 10.3390/cancers12103076] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 10/20/2020] [Indexed: 12/16/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) has a dismal prognosis along with rising incidence rates and will be responsible for many cancer deaths in the future [...].
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8
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Liver metastases from pancreatic ductal adenocarcinoma: is there a place for surgery in the modern era? JOURNAL OF PANCREATOLOGY 2020. [DOI: 10.1097/jp9.0000000000000042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
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9
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Surgery or Locoregional Approaches for Hepatic Oligometastatic Pancreatic Cancer: Myth, Hope, or Reality? Cancers (Basel) 2019; 11:cancers11081095. [PMID: 31374916 PMCID: PMC6721290 DOI: 10.3390/cancers11081095] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 07/27/2019] [Accepted: 07/28/2019] [Indexed: 12/15/2022] Open
Abstract
Despite extensive research, pancreatic ductal adenocarcinoma (PDAC) remains a difficult-to-treat cancer associated with poor survival. Due to the known aggressive disease biology, palliative chemotherapy is the only routinely recommended treatment in the metastatic setting in patients with adequate performance status. However, in a subset of patients with oligometastatic disease, multimodality treatment with surgery and/or locoregional approaches may provide long-term disease control and prolong survival. In fact, in highly selected cases, median overall survival has been reported to extend to 56 months in patients treated with surgery. In particular, liver and extraregional nodal resections may provide long-term tumor control with acceptable morbidity. Current guidelines do not recommend surgery for patients with metastatic PDAC and, in the case of PDAC with oligometastases, there are no published randomized controlled trials regarding locoregional or surgical approaches. Here we review the literature on surgical and locoregional approaches including radiofrequency ablation, irreversible electroporation, and stereotactic body radiation, and focus on patients with hepatic oligometastatic pancreatic cancer. We provide a summary regarding survival outcomes, morbidity and mortality and discuss selection criteria that may be useful to predict the best outcomes for such strategies.
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Klein F, Pelzer U, Schmuck RB, Malinka T, Felsenstein M, Denecke T, Pratschke J, Bahra M. Strengths, Weaknesses, Opportunities, and Threats of Centralized Pancreatic Surgery: a Single-Center Analysis of 3000 Consecutive Pancreatic Resections. J Gastrointest Surg 2019; 23:492-502. [PMID: 30187320 DOI: 10.1007/s11605-018-3867-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 06/27/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pancreatic surgery at high-volume centers has undergone major changes over the last decades. However, the quality of surgery remains to be considered as one important factor for achieving long-term survival especially in patients at advanced stages of disease. METHODS Between January 1990 and June 2017, 3000 consecutive patients have undergone pancreatic resections at our institution. Relevant postoperative data and histopathological findings as well as overall survival were analyzed. In addition, a SWOT (strengths, weaknesses, opportunities, threats) analysis of pancreatic surgery at high-volume centers was performed. RESULTS A total of 2218 pancreatic head resections (74%), 494 distal pancreatectomies (16%), 200 total pancreatectomies (7%), and 88 other resections (3%) were performed within our study period. Despite additional vascular resections in 265 patients (9%) and additional liver resections in 167 patients (6%), overall perioperative mortality did not exceed 3%. Overall survival strongly depended on the underlying disease, as well as on lymph node stage (p = < 0.001) and surgical radicality (p = < 0.001). CONCLUSIONS The decentralization of pancreatic surgery over the last decades has led to a focus on high-volume centers to perform extended procedures in complex patients. The present SWOT analysis underlines the significance of a centralization of pancreatic surgery for patient safety and to increase the chance of long-term survival.
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Affiliation(s)
- Fritz Klein
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Uwe Pelzer
- Department of Hematology, Oncology and Tumor Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Rosa Bianca Schmuck
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Thomas Malinka
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Matthäus Felsenstein
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Timm Denecke
- Department of Diagnostic and Interventional Radiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Marcus Bahra
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
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11
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Andreou A, Knitter S, Klein F, Malinka T, Schmelzle M, Struecker B, Schmuck RB, Noltsch AR, Lee D, Pelzer U, Denecke T, Pratschke J, Bahra M. The role of hepatectomy for synchronous liver metastases from pancreatic adenocarcinoma. Surg Oncol 2018; 27:688-694. [PMID: 30449494 DOI: 10.1016/j.suronc.2018.09.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 08/27/2018] [Accepted: 09/17/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND The role of hepatectomy for patients with liver metastases from ductal adenocarcinoma of the pancreas (PLM) remains controversial. Therefore, the aim of our study was to examine the postoperative morbidity, mortality, and long-term survivals after liver resection for synchronous PLM. METHODS Clinicopathological data of patients who underwent hepatectomy for PLM between 1993 and 2015 were assessed. Major endpoint of this study was to identify predictors of overall survival (OS). RESULTS During the study period, 76 patients underwent resection for pancreatic cancer and concomitant hepatectomy for synchronous PLM. Pancreatoduodenectomy, distal pancreatectomy, and total pancreatectomy were performed in 67%, 25%, and 8% of the patients, respectively. The median PLM size was 1 (1-13) cm and 36% of patients had multiple PLM. The majority of patients (96%) underwent a minor liver resection. After a median follow-up time of 130 months, 1-, 3-, and 5-year OS rates were 41%, 13%, and 7%, respectively. Postoperative morbidity and mortality rates were 50% and 5%, respectively. Preoperative and postoperative chemotherapy was administered to 5% and 72% of patients, respectively. In univariate analysis, type of pancreatic procedure (P = .020), resection and reconstruction of the superior mesenteric artery (P = .016), T4 stage (P = .086), R1 margin status at liver resection (P = .001), lymph node metastases (P = .016), poorly differentiated cancer (G3) (P = .037), no preoperative chemotherapy (P = .013), and no postoperative chemotherapy (P = .005) were significantly associated with worse OS. In the multivariate analysis, poorly differentiated cancer (G3) (hazard ratio [HR] = 1.87; 95% confidence interval [CI] = 1.08-3.24; P = .026), R1 margin status at liver resection (HR = 4.97; 95% CI = 1.46-16.86; P = .010), no preoperative chemotherapy (HR = 4.07; 95% CI = 1.40-11.83; P = .010), and no postoperative chemotherapy (HR = 1.88; 95% CI = 1.06-3.29; P = .030) independently predicted worse OS. CONCLUSIONS Liver resection for PLM is feasible and safe and may be recommended within the framework of an individualized cancer therapy. Multimodal treatment strategy including perioperative chemotherapy and hepatectomy may provide prolonged survival in selected patients with metastatic pancreatic cancer.
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Affiliation(s)
- Andreas Andreou
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Charité Mitte and Campus Virchow Klinikum, Germany.
| | - Sebastian Knitter
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Charité Mitte and Campus Virchow Klinikum, Germany; Berlin Institute of Health (BIH), Berlin, Germany
| | - Fritz Klein
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Charité Mitte and Campus Virchow Klinikum, Germany
| | - Thomas Malinka
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Charité Mitte and Campus Virchow Klinikum, Germany
| | - Moritz Schmelzle
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Charité Mitte and Campus Virchow Klinikum, Germany
| | - Benjamin Struecker
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Charité Mitte and Campus Virchow Klinikum, Germany; Berlin Institute of Health (BIH), Berlin, Germany
| | - Rosa B Schmuck
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Charité Mitte and Campus Virchow Klinikum, Germany; Berlin Institute of Health (BIH), Berlin, Germany
| | - Alina Roxana Noltsch
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Charité Mitte and Campus Virchow Klinikum, Germany
| | - Daniela Lee
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Charité Mitte and Campus Virchow Klinikum, Germany
| | - Uwe Pelzer
- Department of Hematology, Oncology and Tumor Immunology, Charité - Universitätsmedizin Berlin, Campus Charité Mitte and Campus Virchow Klinikum, Germany
| | - Timm Denecke
- Department of Radiology, Charité - Universitätsmedizin Berlin, Campus Charité Mitte and Campus Virchow Klinikum, Germany
| | - Johann Pratschke
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Charité Mitte and Campus Virchow Klinikum, Germany
| | - Marcus Bahra
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Charité Mitte and Campus Virchow Klinikum, Germany
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12
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Routine portal vein resection for pancreatic adenocarcinoma shows no benefit in overall survival. Eur J Surg Oncol 2018; 44:1094-1099. [PMID: 29778616 DOI: 10.1016/j.ejso.2018.05.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 04/27/2018] [Accepted: 05/02/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Extended pancreatic resections including resections of the portal (PV) may nowadays be performed safely. Limitations in distinguishing tumor involvement from inflammatory adhesions however lead to portal vein resections (PVR) without evidence of tumor infiltration in the final histopathological examination. The aim of this study was to analyze the impact of these "false negative" resections on operative outcome and long-term survival. METHODS 40 patients who underwent pancreatic resection with PVR for pancreatic adenocarcinoma (PA) without tumor infiltration of the PV (PVR-group) were identified. In a 1:3 match these patients were compared to 120 patients after standard pancreatic resection without PVR (SPR-group) with regard to operative outcome and overall survival. RESULTS Survival analysis revealed that median survival was significantly shorter in the PVR group (311 days) as compared to the SPR group (558 days), (p = 0.0011, hazard ratio 1.98, 95% CI: 1.31-2.98). Also postoperative complications ≥ Clavien III occurred significantly more often in the PVR group (37.5% vs. 20.8%). CONCLUSIONS Radical resection affords the best chance for long-term survival in patients with PA. Based on the results of this study a routine resection of the PV as recently proposed may however not be recommended.
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13
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Dose-escalated radiotherapy for unresectable or locally recurrent pancreatic cancer: Dose volume analysis, toxicity and outcome of 28 consecutive patients. PLoS One 2017; 12:e0186341. [PMID: 29023527 PMCID: PMC5638513 DOI: 10.1371/journal.pone.0186341] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 10/01/2017] [Indexed: 01/10/2023] Open
Abstract
PURPOSE The role of radiotherapy for unresectable pancreatic cancer is controversial. A benefit of additional radiotherapy is supported by some observations. A dose-effect relationship was recently found by dose escalation employing image guided and intensity modulated radiotherapy. METHODS We retrospectively evaluated 28 consecutive patients, all with history of extensive prior therapies for unresectable locally advanced/ recurrent pancreatic cancer (LAPC/LRPC). Treatment was delivered by helical tomotherapy after daily position verification with computed tomography. Dose to the planned target volume (PTV) was 51 Gy, while the dose to the macroscopic tumor was escalated by a simultaneous integrated boost to a median cumulative dose of 66 Gy (60-66 Gy). Concomitant chemotherapy consisted mainly of capecitabine (n = 23). RESULTS 10 of 28 patients presented acute toxicities > grade 2, one patient succumbed to gastrointestinal bleeding after treatment. No correlations of toxicities and dose volume histograms (DVH) of retrospectively delineated small bowel loops were observed, although average small bowel volume receiving ≥ 20 Gy was 374 ml. DVH analyses revealed a correlation of splenic parameters and acute toxicity: Vomiting, anorexia, dehydration, hematologic toxicity, fatigue, combined gastro-intestinal toxicity wit R-values between 0.392 and 0.561 (all p-values > 0.05). Only one patient developed late toxicities > grade 2. With an average follow-up time in surviving patients of 14 months median overall survival time was 19 months and median time to local recurrence 13 months. In 8 patients with available imaging of local recurrence: 5 in field recurrences, 2 marginal recurrences and one lymph node recurrence outside the high dose radiation field were observed. In univariate analysis only ΔCA-19-9 during radiotherapy was associated with local control (p = 0.029) and overall survival (p = 0.049). CONCLUSION Dose escalated normo-fractionated radiotherapy for LAPC/LRPC seems feasible and suitable to prolong local control and in consequence long-term survival. However, in-field local progression is still frequently observed and possibilities to increase the local effectiveness should be evaluated. Exposure of the spleen was predictive for acute toxicity and should be further investigated.
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14
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Bryan RB, Gough MJ, Seung SK, Jutric Z, Weinberg AD, Fox BA, Crittenden MR, Leidner RS, Curti B. Cytoreductive surgery for head and neck squamous cell carcinoma in the new age of immunotherapy. Oral Oncol 2016; 61:166-76. [PMID: 27614589 DOI: 10.1016/j.oraloncology.2016.08.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 08/30/2016] [Indexed: 12/11/2022]
Abstract
Cytoreductive surgery is an approach to cancer treatment that aims to reduce the number of cancer cells via resection of primary tumor or metastatic deposits, in an effort to minimize a potentially immunosuppressive tumor burden, palliate symptoms, and prevent complications. Furthermore, it provides a platform for investigation of biomarkers with the goal of optimizing immunotherapy to reverse the immunosuppressive tumor microenvironment and enhance adaptive immune responses. Ultimately, our group aims to exploit the concept that successful cancer therapy is dependent upon an effective immune response. Surgery will remain an integral part of head and neck squamous cell carcinoma (HNSCC) treatment in the future, even as checkpoint inhibitors, co-stimulatory molecules, vaccines, adoptive T cell therapy and other novel agents enter clinical routine. Cytoreductive resection may provide an effective platform for immunotherapy and biomarker directed interventions to improve outcomes for patients with HNSCC.
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Affiliation(s)
- R Bryan Bryan
- Earle A. Chiles Research Institute at Providence Cancer Center, 4805 NE Glisan St. Suite 2N35, Portland, OR 97213, United States; Providence Oral, Head and Neck Cancer Program and Clinic, Providence Cancer Center, Providence Portland Medical Center, 4805 NE Glisan St. Suite 6N50, Portland, OR 97213, United States; Head and Neck Institute, 1849 NW Kearney, Suite 300, Portland, OR 97209, United States.
| | - Michael J Gough
- Earle A. Chiles Research Institute at Providence Cancer Center, 4805 NE Glisan St. Suite 2N35, Portland, OR 97213, United States
| | - Steven K Seung
- Earle A. Chiles Research Institute at Providence Cancer Center, 4805 NE Glisan St. Suite 2N35, Portland, OR 97213, United States; Providence Oral, Head and Neck Cancer Program and Clinic, Providence Cancer Center, Providence Portland Medical Center, 4805 NE Glisan St. Suite 6N50, Portland, OR 97213, United States; The Oregon Clinic, Department of Radiation Oncology, 4805 NE Glisan St., Portland, OR 97213, United States
| | - Zeljka Jutric
- Earle A. Chiles Research Institute at Providence Cancer Center, 4805 NE Glisan St. Suite 2N35, Portland, OR 97213, United States
| | - Andrew D Weinberg
- Earle A. Chiles Research Institute at Providence Cancer Center, 4805 NE Glisan St. Suite 2N35, Portland, OR 97213, United States
| | - Bernard A Fox
- Earle A. Chiles Research Institute at Providence Cancer Center, 4805 NE Glisan St. Suite 2N35, Portland, OR 97213, United States
| | - Marka R Crittenden
- Earle A. Chiles Research Institute at Providence Cancer Center, 4805 NE Glisan St. Suite 2N35, Portland, OR 97213, United States; Providence Oral, Head and Neck Cancer Program and Clinic, Providence Cancer Center, Providence Portland Medical Center, 4805 NE Glisan St. Suite 6N50, Portland, OR 97213, United States; The Oregon Clinic, Department of Radiation Oncology, 4805 NE Glisan St., Portland, OR 97213, United States
| | - Rom S Leidner
- Earle A. Chiles Research Institute at Providence Cancer Center, 4805 NE Glisan St. Suite 2N35, Portland, OR 97213, United States; Providence Oral, Head and Neck Cancer Program and Clinic, Providence Cancer Center, Providence Portland Medical Center, 4805 NE Glisan St. Suite 6N50, Portland, OR 97213, United States
| | - Brendan Curti
- Earle A. Chiles Research Institute at Providence Cancer Center, 4805 NE Glisan St. Suite 2N35, Portland, OR 97213, United States
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Sinn M, Bahra M, Denecke T, Travis S, Pelzer U, Riess H. Perioperative treatment options in resectable pancreatic cancer - how to improve long-term survival. World J Gastrointest Oncol 2016; 8:248-57. [PMID: 26989460 PMCID: PMC4789610 DOI: 10.4251/wjgo.v8.i3.248] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 12/01/2015] [Accepted: 12/18/2015] [Indexed: 02/05/2023] Open
Abstract
Surgery remains the only chance of cure for pancreatic cancer, but only 15%-25% of patients present with resectable disease at the time of primary diagnosis. Important goals in clinical research must therefore be to allow early detection with suitable diagnostic procedures, to further broaden operation techniques and to determine the most effective perioperative treatment of either chemotherapy and/or radiation therapy. More extensive operations involving extended pancreatectomy, portal vein resection and pancreatic resection in resectable pancreatic cancer with limited liver metastasis, performed in specialized centers seem to be the surgical procedures with a possible impact on survival. After many years of stagnation in pharmacological clinical research on advanced pancreatic ductal adenocarcinomas (PDAC) - since the approval of gemcitabine in 1997 - more effective cytotoxic substances (nab-paclitaxel) and combinations (FOLFIRINOX) are now available for perioperative treatment. Additionally, therapies with a broader mechanism of action are emerging (stroma depletion, immunotherapy, anti-inflammation), raising hopes for more effective adjuvant and neoadjuvant treatment concepts, especially in the context of "borderline resectability". Only multidisciplinary approaches including radiology, surgery, medical and radiation oncology as the backbones of the treatment of potentially resectable PDAC may be able to further improve the rate of cure in the future.
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