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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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Ansari D, Søreide K, Andersson B, Hansen CP, Seppänen H, Sparrelid E, Labori KJ, Kirkegård J, Kauhanen S, Månsson C, Nymo LS, Nortunen M, Björnsson B, Kivivuori A, Tingstedt B, Bratlie SO, Waardal K, Laukkarinen J, Halimi A, Lindberg H, Olin H, Andersson R. Surveillance after surgery for pancreatic cancer: a global scoping review of guidelines and a nordic Survey of contemporary practice. Scand J Gastroenterol 2024; 59:1097-1104. [PMID: 38994854 DOI: 10.1080/00365521.2024.2378948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 06/24/2024] [Accepted: 07/06/2024] [Indexed: 07/13/2024]
Abstract
OBJECTIVES Most patients with pancreatic cancer who have undergone surgical resection eventually develop disease recurrence. This study aimed to investigate whether there is evidence to support routine surveillance after pancreatic cancer surgery, with a secondary aim of analyzing the implementation of surveillance strategies in the Nordic countries. MATERIALS AND METHODS A scoping review was conducted to identify clinical practice guidelines globally and research studies relating to surveillance after pancreatic cancer resection. This was followed by a survey among 20 pancreatic units from four Nordic countries to assess their current practice of follow-up for operated patients. RESULTS Altogether 16 clinical practice guidelines and 17 research studies were included. The guidelines provided inconsistent recommendations regarding postoperative surveillance of pancreatic cancer. The clinical research data were mainly based on retrospective cohort studies with low level of evidence and lead-time bias was not addressed. Active surveillance was recommended in Sweden and Denmark, but not in Norway beyond the post-operative/adjuvant period. Finland had no national recommendations for surveillance. The Nordic survey revealed a wide variation in reported practice among the different units. About 75% (15 of 20 units) performed routine postoperative surveillance. Routine CA 19-9 testing was used by 80% and routine CT by 67% as part of surveillance. About 73% of centers continued follow-up until 5 years postoperatively. CONCLUSION Evidence for routine long-term (i.e. 5 years) surveillance after pancreatic cancer surgery remains limited. Most pancreatic units in the Nordic countries conduct regular follow-up, but protocols vary.
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Affiliation(s)
- Daniel Ansari
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Bodil Andersson
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | | | - Hanna Seppänen
- Department of Gastrointestinal Surgery, Meilahti Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ernesto Sparrelid
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Knut Jørgen Labori
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jakob Kirkegård
- Department of Surgery, HPB Section, Aarhus University Hospital, Aarhus, Denmark
| | - Saila Kauhanen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | | | - Linn Såve Nymo
- Department of Gastrointestinal Surgery, University Hospital of North Norway, Tromsø, Norway
| | - Minna Nortunen
- Department of Surgery, Oulu University Hospital and Medical Research Center Oulu, Oulu, Finland
| | - Bergthor Björnsson
- Department of Surgery in Linköping and Department of Biomedicine and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Antti Kivivuori
- Department of Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Bobby Tingstedt
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Svein-Olav Bratlie
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kim Waardal
- Department of Acute and Digestive Surgery, Haukeland University Hospital, Bergen, Norway
| | - Johanna Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Finland
| | - Asif Halimi
- Department of Diagnostics and Intervention, Surgery, Umeå University, Umeå, Sweden
| | - Hannes Lindberg
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Håkan Olin
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Roland Andersson
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
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3
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Piemonti L, Melzi R, Aleotti F, Capretti G, Nano R, Mercalli A, Magistretti P, Caldara R, Pecorelli N, Catarinella D, Gremizzi C, Gavazzi F, De Cobelli F, Poretti D, Falconi M, Zerbi A, Balzano G. Autologous Pancreatic Islet Cell Transplantation Following Pancreatectomy for Pancreas Diseases Other Than Chronic Pancreatitis: A 15-y Study of the Milan Protocol. Transplantation 2024; 108:1962-1975. [PMID: 38637923 PMCID: PMC11335085 DOI: 10.1097/tp.0000000000005037] [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: 09/22/2023] [Revised: 01/23/2024] [Accepted: 02/20/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Pancreatogenic diabetes, a consequence of pancreatic tissue loss following pancreatectomy, poses a significant challenge for patients undergoing pancreatic surgery. Islet autotransplantation (IAT) offers a promising approach to prevent or alleviate pancreatogenic diabetes, but its application has been limited to individuals with painful chronic pancreatitis. METHODS This study presents a 15-y clinical experience with the Milan Protocol, which expands IAT after pancreatectomy to a broader spectrum of patients with malignant and nonmalignant pancreatic diseases. The analysis evaluates feasibility, efficacy, and safety of IAT. Modified Igls criteria validated through the arginine test and mixed meal tolerance tests were used to assess long-term metabolic outcomes. RESULTS Between November 2008 and June 2023, IAT procedures were performed on 114 of 147 candidates. IAT-related complications occurred in 19 of 114 patients (16.7%), with 5 being potentially serious. Patients exhibited sustained C-peptide secretion over the 10-y follow-up period, demonstrating a prevalence of optimal and good beta-cell function. Individuals who underwent partial pancreatectomy demonstrated superior metabolic outcomes, including sustained C-peptide secretion and a reduced risk of developing diabetes or insulin dependence compared with those who underwent total pancreatectomy. For patients who had total pancreatectomy, the quantity of infused islets and tissue volume were identified as critical factors influencing metabolic outcomes. An increased risk of recurrence or progression of baseline diseases was not observed in subjects with neoplasms. CONCLUSIONS These findings provide valuable insights into the benefits and applications of IAT as a therapeutic option for pancreatogenic diabetes after pancreatic surgery, expanding its potential beyond painful chronic pancreatitis.
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Affiliation(s)
- Lorenzo Piemonti
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
- Università Vita-Salute San Raffaele, Milan, Italy
| | - Raffella Melzi
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Francesca Aleotti
- Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Giovanni Capretti
- Department of Pancreatic Surgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Rita Nano
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alessia Mercalli
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Paola Magistretti
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Rossana Caldara
- Clinic Unit of Regenerative Medicine and Organ Transplants, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Nicolò Pecorelli
- Università Vita-Salute San Raffaele, Milan, Italy
- Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Davide Catarinella
- Clinic Unit of Regenerative Medicine and Organ Transplants, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Chiara Gremizzi
- Clinic Unit of Regenerative Medicine and Organ Transplants, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Francesca Gavazzi
- Department of Pancreatic Surgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Francesco De Cobelli
- Università Vita-Salute San Raffaele, Milan, Italy
- Department of Radiology, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Dario Poretti
- Department of Radiology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Massimo Falconi
- Università Vita-Salute San Raffaele, Milan, Italy
- Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alessandro Zerbi
- Department of Pancreatic Surgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Gianpaolo Balzano
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
- Università Vita-Salute San Raffaele, Milan, Italy
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4
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Mohamed SA, Barlemann A, Steinle V, Nonnenmacher T, Güttlein M, Hackert T, Loos M, Gaida MM, Kauczor HU, Klauss M, Mayer P. Performance of different CT enhancement quantification methods as predictors of pancreatic cancer recurrence after upfront surgery. Sci Rep 2024; 14:19783. [PMID: 39187515 PMCID: PMC11347575 DOI: 10.1038/s41598-024-70441-3] [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: 03/07/2024] [Accepted: 08/16/2024] [Indexed: 08/28/2024] Open
Abstract
The prognosis of pancreatic cancer (PDAC) after tumor resection remains poor, mostly due to a high but variable risk of recurrence. A promising tool for improved prognostication is the quantification of CT tumor enhancement. For this, various enhancement formulas have been used in previous studies. However, a systematic comparison of these formulas is lacking. In the present study, we applied twenty-three previously published CT enhancement formulas to our cohort of 92 PDAC patients who underwent upfront surgery. We identified seven formulas that could reliably predict tumor recurrence. Using these formulas, weak tumor enhancement was associated with tumor recurrence at one and two years after surgery (p ≤ 0.030). Enhancement was inversely associated with adverse clinicopathological features. Low enhancement values were predictive of a high recurrence risk (Hazard Ratio ≥ 1.659, p ≤ 0.028, Cox regression) and a short time to recurrence (TTR) (p ≤ 0.027, log-rank test). Some formulas were independent predictors of TTR in multivariate models. Strikingly, almost all of the best-performing formulas measure solely tumor tissue, suggesting that normalization to non-tumor structures might be unnecessary. Among the top performers were also the absolute arterial/portal venous tumor attenuation values. These can be easily implemented in clinical practice for better recurrence prediction, thus potentially improving patient management.
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Affiliation(s)
- Sherif A Mohamed
- Clinic for Diagnostic and Interventional Radiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany.
- Department of Neuroradiology, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Alina Barlemann
- Clinic for Diagnostic and Interventional Radiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Verena Steinle
- Clinic for Diagnostic and Interventional Radiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Tobias Nonnenmacher
- Clinic for Diagnostic and Interventional Radiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Michelle Güttlein
- Clinic for Diagnostic and Interventional Radiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Loos
- Clinic of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Matthias M Gaida
- Institute of Pathology, University Medical Center Mainz, JGU-Mainz, Mainz, Germany
- TRON, Translational Oncology at the University Medical Center, JGU-Mainz, Mainz, Germany
| | - Hans-Ulrich Kauczor
- Clinic for Diagnostic and Interventional Radiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Miriam Klauss
- Clinic for Diagnostic and Interventional Radiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Philipp Mayer
- Clinic for Diagnostic and Interventional Radiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany.
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Patel RK, Salgado-Garza G, Sutton TL, Phipps JL, Papavasiliou P, Gerry JM, Johnson AJ, Rocha FG, Sheppard BC, Worth PJ. Rapid metastatic recurrence after pancreatic cancer resection: a multi-center, regional analysis of trends in surgical failure over two decades. HPB (Oxford) 2024:S1365-182X(24)02255-X. [PMID: 39242329 DOI: 10.1016/j.hpb.2024.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 06/07/2024] [Accepted: 08/05/2024] [Indexed: 09/09/2024]
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAc) is a lethal malignancy, attributed in part to high rates of rapid recurrence (rrPDAc) following resection. We sought to characterize recurrence rates over time and investigate factors predictive of rrPDAc. METHODS A regional multi-institutional cancer registry, augmented with data from the National Surgical Quality Improvement Program database, was queried for patients with PDAc from 1996 to 2020. rrPDAc was defined as recurrence within 6 months following curative-intent resection. RESULTS We identified 924 patients who underwent resection for PDAc; rrPDAc occurred in 236 (26%) patients. Median incidence of rrPDAc was 25.3% (IQR 22-30.2%) per year. Median survival in rrPDAc, non-rapid recurrence, and no recurrence was 10.3, 25.2, and 56.1 months respectively (p < 0.001). Variables independently associated with greater odds of rrPDAc included surgical site infection (SSI) (OR 2.06) and nodal positivity (OR 2.05); adjuvant therapy was associated with lower odds (OR 0.38). Neoadjuvant chemotherapy did not alter risk of rrPDAc. Three-year post-recurrence survival was no different in rrPDAc versus those without. CONCLUSION Despite therapeutic advances, incidence of rrPDAc remains unchanged. SSIs and nodal positivity are independently associated with increased risk of rrPDAc, while adjuvant chemotherapy is associated with lower risk. Strategies focused on preventing rapid recurrence may improve survival.
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Affiliation(s)
- Ranish K Patel
- Oregon Health & Science University (OHSU), Department of Surgery, Portland, OR 97239, USA
| | - Gustavo Salgado-Garza
- Oregon Health & Science University (OHSU), Department of Surgery, Portland, OR 97239, USA
| | - Thomas L Sutton
- Oregon Health & Science University (OHSU), Department of Surgery, Portland, OR 97239, USA
| | - Jackie L Phipps
- Oregon Health & Science University (OHSU), Department of Surgery, Portland, OR 97239, USA
| | | | - Jon M Gerry
- The Oregon Clinic, Center for Advanced Surgery, Portland, OR 97213, USA
| | - Alicia J Johnson
- Oregon Health & Science University (OHSU), Department of Surgery, Portland, OR 97239, USA
| | - Flavio G Rocha
- Oregon Health & Science University (OHSU), Department of Surgery, Portland, OR 97239, USA; The Knight Cancer Institute, OHSU, Portland, OR 97239, USA; Brenden Colson Center for Pancreatic Care, OHSU, Portland, OR, USA
| | - Brett C Sheppard
- Oregon Health & Science University (OHSU), Department of Surgery, Portland, OR 97239, USA; The Knight Cancer Institute, OHSU, Portland, OR 97239, USA; Brenden Colson Center for Pancreatic Care, OHSU, Portland, OR, USA
| | - Patrick J Worth
- Oregon Health & Science University (OHSU), Department of Surgery, Portland, OR 97239, USA; The Knight Cancer Institute, OHSU, Portland, OR 97239, USA; Brenden Colson Center for Pancreatic Care, OHSU, Portland, OR, USA.
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6
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Alaref A, Siltamaki D, Cerasuolo JO, Akhtar-Danesh N, Caswell JM, Serrano PE, Meyers BM, Savage DW, Nelli J, Patlas M, Alabousi A, Siddiqui R, van der Pol CB. Impact of pre-operative abdominal MRI on survival for patients with resected pancreatic carcinoma: a population-based study. LANCET REGIONAL HEALTH. AMERICAS 2024; 35:100809. [PMID: 38948322 PMCID: PMC11214329 DOI: 10.1016/j.lana.2024.100809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 05/21/2024] [Accepted: 05/27/2024] [Indexed: 07/02/2024]
Abstract
Background This study determined the impact of pre-operative abdominal MRI on all-cause mortality for patients with resected PDAC. Methods All adult (≥18 years) PDAC patients who underwent pancreatectomy between January 2011 and December 2022 in Ontario, Canada, were identified for this population-based cohort study (ICD-O-3 codes: C250, C251, C252, C253, C257, C258). Patient demographics, comorbidities, PDAC stage, medical and surgical management, and survival data were sourced from multiple linked provincial administrative databases at ICES. All-cause mortality was compared between patients with and without a pre-operative abdominal MRI after controlling for multiple covariates. Findings A cohort of 4579 patients consisted of 2432 men (53.1%) and 2147 women (46.9%) with a mean age of 65.2 years (standard deviation: 11.2 years); 2998 (65.5%) died while 1581 (34.5%) survived. Median follow-up duration post-resection was 22.4 months (interquartile range: 10.8-48.8 months), and median survival post-pancreatectomy was 25.9 months (95% confidence interval [95% CI]: 24.8, 27.5). Patients who underwent a pre-operative abdominal MRI had a median survival of 33.1 months (95% CI: 30.7, 37.2) compared to 21.1 months (95% CI: 19.8, 22.6) for all others. A total of 2354/4579 (51.4%) patients underwent a pre-operative abdominal MRI, which was associated with a 17.2% (95% CI: 11.0, 23.1) decrease in the rate of all-cause mortality, with an adjusted hazard ratio (aHR) of 0.828 (95% CI: 0.769, 0.890). Interpretation Pre-operative abdominal MRI was associated with improved overall survival for PDAC patients who underwent pancreatectomy, possibly due to better detection of liver metastases than CT. Funding Northern Ontario Academic Medicine Association (NOAMA) Clinical Innovation Fund.
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Affiliation(s)
- Amer Alaref
- NOSM University, Thunder Bay, Ontario, Canada
- Thunder Bay Regional Health Sciences Centre (TBRHSC), Thunder Bay, Ontario, Canada
| | - Dylan Siltamaki
- NOSM University, Thunder Bay, Ontario, Canada
- Thunder Bay Regional Health Sciences Centre (TBRHSC), Thunder Bay, Ontario, Canada
| | - Joshua O. Cerasuolo
- ICES North, Health Sciences North Research Institute, Sudbury, Ontario, Canada
| | - Noori Akhtar-Danesh
- ICES McMaster, Faculty of Health Sciences, Hamilton, Ontario, Canada
- McMaster University, Hamilton, Ontario, Canada
| | - Joseph M. Caswell
- ICES North, Health Sciences North Research Institute, Sudbury, Ontario, Canada
| | - Pablo E. Serrano
- McMaster University, Hamilton, Ontario, Canada
- Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Brandon M. Meyers
- McMaster University, Hamilton, Ontario, Canada
- Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
- Escarpment Cancer Research Institute, Hamilton, Ontario, Canada
| | - David W. Savage
- NOSM University, Thunder Bay, Ontario, Canada
- Thunder Bay Regional Health Sciences Centre (TBRHSC), Thunder Bay, Ontario, Canada
- ICES North, Health Sciences North Research Institute, Sudbury, Ontario, Canada
| | - Jennifer Nelli
- McMaster University, Hamilton, Ontario, Canada
- Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | | - Abdullah Alabousi
- McMaster University, Hamilton, Ontario, Canada
- St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Rabail Siddiqui
- Thunder Bay Regional Health Research Institute, Thunder Bay, Ontario, Canada
| | - Christian B. van der Pol
- McMaster University, Hamilton, Ontario, Canada
- Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
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7
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Daamen LA, van Goor IWJM, Groot VP, Andel PCM, Brosens LAA, Busch OR, Cirkel GA, Mohammad NH, Heerkens HD, de Hingh IHJT, Hoogwater F, van Laarhoven HWM, Los M, Meijer GJ, de Meijer VE, Pande R, Roberts KJ, Stoker J, Stommel MWJ, van Tienhoven G, Verdonk RC, Verkooijen HM, Wessels FJ, Wilmink JW, Besselink MG, van Santvoort HC, Intven MPW, Molenaar IQ. Recurrent disease detection after resection of pancreatic ductal adenocarcinoma using a recurrence-focused surveillance strategy (RADAR-PANC): protocol of an international randomized controlled trial according to the Trials within Cohorts design. Trials 2024; 25:401. [PMID: 38902836 PMCID: PMC11188210 DOI: 10.1186/s13063-024-08223-5] [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: 03/20/2024] [Accepted: 06/03/2024] [Indexed: 06/22/2024] Open
Abstract
BACKGROUND Disease recurrence remains one of the biggest concerns in patients after resection of pancreatic ductal adenocarcinoma (PDAC). Despite (neo)adjuvant systemic therapy, most patients experience local and/or distant PDAC recurrence within 2 years. High-level evidence regarding the benefits of recurrence-focused surveillance after PDAC resection is missing, and the impact of early detection and treatment of recurrence on survival and quality of life is unknown. In most European countries, recurrence-focused follow-up after surgery for PDAC is currently lacking. Consequently, guidelines regarding postoperative surveillance are based on expert opinion and other low-level evidence. The recent emergence of more potent local and systemic treatment options for PDAC recurrence has increased interest in early diagnosis. To determine whether early detection and treatment of recurrence can lead to improved survival and quality of life, we designed an international randomized trial. METHODS This randomized controlled trial is nested within an existing prospective cohort in pancreatic cancer centers in the Netherlands (Dutch Pancreatic Cancer Project; PACAP) and the United Kingdom (UK) (Pancreas Cancer: Observations of Practice and survival; PACOPS) according to the "Trials within Cohorts" (TwiCs) design. All PACAP/PACOPS participants with a macroscopically radical resection (R0-R1) of histologically confirmed PDAC, who provided informed consent for TwiCs and participation in quality of life questionnaires, are included. Participants randomized to the intervention arm are offered recurrence-focused surveillance, existing of clinical evaluation, serum cancer antigen (CA) 19-9 testing, and contrast-enhanced computed tomography (CT) of chest and abdomen every three months during the first 2 years after surgery. Participants in the control arm of the study will undergo non-standardized clinical follow-up, generally consisting of clinical follow-up with imaging and serum tumor marker testing only in case of onset of symptoms, according to local practice in the participating hospital. The primary endpoint is overall survival. Secondary endpoints include quality of life, patterns of recurrence, compliance to and costs of recurrence-focused follow-up, and the impact on recurrence-focused treatment. DISCUSSION The RADAR-PANC trial will be the first randomized controlled trial to generate high level evidence for the current clinical equipoise regarding the value of recurrence-focused postoperative surveillance with serial tumor marker testing and routine imaging in patients after PDAC resection. The Trials within Cohort design allows us to study the acceptability of recurrence-focused surveillance among cohort participants and increases the generalizability of findings to the general population. While it is strongly encouraged to offer all trial participants treatment at time of recurrence diagnosis, type and timing of treatment will be determined through shared decision-making. This might reduce the potential survival benefits of recurrence-focused surveillance, although insights into the impact on patients' quality of life will be obtained. TRIAL REGISTRATION Clinicaltrials.gov, NCT04875325 . Registered on May 6, 2021.
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Affiliation(s)
- L A Daamen
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands
- Division of Imaging, UMC Utrecht Cancer Center, Utrecht University, Utrecht, the Netherlands
| | - I W J M van Goor
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands.
- Department of Radiation Oncology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands.
| | - V P Groot
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands
| | - P C M Andel
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands
| | - L A A Brosens
- Department of Pathology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands
- Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - O R Busch
- Amsterdam UMC, Department of Surgery, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - G A Cirkel
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center, St. Antonius Hospital Nieuwegein & Meander Medical Center, Utrecht University, Utrecht, the Netherlands
| | - N Haj Mohammad
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center, St. Antonius Hospital Nieuwegein & Meander Medical Center, Utrecht University, Utrecht, the Netherlands
| | - H D Heerkens
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - I H J T de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - F Hoogwater
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - H W M van Laarhoven
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Amsterdam UMC, Department of Medical Oncology, Location University of Amsterdam, Amsterdam, the Netherlands
| | - M Los
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center, St. Antonius Hospital Nieuwegein & Meander Medical Center, Utrecht University, Utrecht, the Netherlands
| | - G J Meijer
- Department of Radiation Oncology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands
| | - V E de Meijer
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - R Pande
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK
| | - K J Roberts
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - J Stoker
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Amsterdam UMC, Department of Radiology, Location University of Amsterdam, Amsterdam, the Netherlands
| | - M W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - G van Tienhoven
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Amsterdam UMC, Department of Radiation Oncology, Location University of Amsterdam, Amsterdam, the Netherlands
| | - R C Verdonk
- Department of Gastroenterology and Hepatology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands
| | - H M Verkooijen
- Division of Imaging, UMC Utrecht Cancer Center, Utrecht University, Utrecht, the Netherlands
| | - F J Wessels
- Department of Radiology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands
| | - J W Wilmink
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Amsterdam UMC, Department of Medical Oncology, Location University of Amsterdam, Amsterdam, the Netherlands
| | - M G Besselink
- Amsterdam UMC, Department of Surgery, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - H C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands
| | - M P W Intven
- Department of Radiation Oncology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands
| | - I Q Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands
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8
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Groot VP, Daamen LA. Response to: Comment on "Dynamics of Serum CA 19-9 in Patients Undergoing Pancreatic Cancer Resection". ANNALS OF SURGERY OPEN 2024; 5:e399. [PMID: 38911646 PMCID: PMC11191980 DOI: 10.1097/as9.0000000000000399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 02/13/2024] [Indexed: 06/25/2024] Open
Affiliation(s)
- Vincent P. Groot
- From the Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center, St. Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
| | - Lois A. Daamen
- From the Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center, St. Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
- Division of Imaging and Oncology, UMC Utrecht Cancer Center, Utrecht University, Utrecht, The Netherlands
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9
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Safyan RA, Kim E, Dekker E, Homs M, Aguirre AJ, Koerkamp BG, Chiorean EG. Multidisciplinary Standards and Evolving Therapies for Patients With Pancreatic Cancer. Am Soc Clin Oncol Educ Book 2024; 44:e438598. [PMID: 38781541 DOI: 10.1200/edbk_438598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Pancreatic ductal adenocarcinoma (PDA) is a challenging disease that presents at an advanced stage and results in many symptoms that negatively influence patients' quality of life and reduce their ability to receive effective treatment. Early implementation of expert multidisciplinary care with nutritional support, exercise, and palliative care for both early-stage and advanced disease promises to maintain or improve the patients' physical, social, and psychological well-being, decrease aggressive interventions at the end of life, and ultimately improve survival. Moreover, advances in treatment strategies in the neoadjuvant and metastatic setting combined with novel therapeutic agents targeting the key drivers of the disease are leading to improvements in the care of patients with pancreatic cancer. Here, we emphasize the multidisciplinary supportive and therapeutic care of patients with PDA, review current guidelines and new developments of neoadjuvant and perioperative treatments for localized disease, as well as the treatment standards and the evolving field of precision oncology and immunotherapies for advanced PDA.
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Affiliation(s)
- Rachael A Safyan
- University of Washington School of Medicine, Department of Medicine, Division of Hematology-Oncology, Seattle, WA
- Fred Hutchinson Cancer Center, Clinical Research Division, Seattle, WA
| | - Eejung Kim
- Dana-Farber Cancer Center, Department of Medical Oncology, Boston, MA
- Harvard Medical School, Boston, MA
| | - Emmelie Dekker
- Erasmus MC Cancer Institute, Department of Surgery, Rotterdam, the Netherlands
| | - Marjolein Homs
- Erasmus MC Cancer Institute, Department of Medical Oncology, Rotterdam, the Netherlands
| | - Andrew J Aguirre
- Dana-Farber Cancer Center, Department of Medical Oncology, Boston, MA
- Harvard Medical School, Boston, MA
| | - Bas Groot Koerkamp
- Erasmus MC Cancer Institute, Department of Surgery, Rotterdam, the Netherlands
| | - E Gabriela Chiorean
- University of Washington School of Medicine, Department of Medicine, Division of Hematology-Oncology, Seattle, WA
- Fred Hutchinson Cancer Center, Clinical Research Division, Seattle, WA
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10
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Abdelrahim M, Esmail A, Kasi A, Esnaola NF, Xiu J, Baca Y, Weinberg BA. Comparative molecular profiling of pancreatic ductal adenocarcinoma of the head versus body and tail. NPJ Precis Oncol 2024; 8:85. [PMID: 38582894 PMCID: PMC10998911 DOI: 10.1038/s41698-024-00571-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 02/29/2024] [Indexed: 04/08/2024] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) of the head (H) and body/tail (B/T) differ in embryonic origin, cell composition, blood supply, lymphatic and venous drainage, and innervation. We aimed to compare the molecular and tumor immune microenvironment (TIME) profiles of PDAC of the H vs. B/T. A total of 3499 PDAC samples were analyzed via next-generation sequencing (NGS) of RNA (whole transcriptome, NovaSeq), DNA (NextSeq, 592 genes or NovaSeq, whole exome sequencing), and immunohistochemistry (Caris Life Sciences, Phoenix, AZ). Significance was determined as p values adjusted for multiple corrections (q) of <0.05. Anatomic subsites of PDAC tumors were grouped by primary tumor sites into H (N = 2058) or B/T (N = 1384). There were significantly more metastatic tumors profiled from B/T vs. H (57% vs. 44%, p < 0.001). KRAS mutations (93.8% vs. 90.2%), genomic loss of heterozygosity (12.7% vs. 9.1%), and several copy number alterations (FGF3, FGF4, FGF19, CCND1, ZNF703, FLT4, MUTYH, TNFRS14) trended higher in B/T when compared to H (p < 0.05 but q > 0.05). Expression analysis of immuno-oncology (IO)-related genes showed significantly higher expression of CTLA4 and PDCD1 in H (q < 0.05, fold change 1.2 and 1.3) and IDO1 and PDCD1LG2 expression trended higher in B/T (p < 0.05, fold change 0.95). To our knowledge, this is one of the largest cohorts of PDAC tumors subjected to broad molecular profiling. Differences in IO-related gene expression and TIME cell distribution suggest that response to IO therapies may differ in PDAC arising from H vs. B/T. Subtle differences in the genomic profiles of H vs. B/T tumors were observed.
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Affiliation(s)
- Maen Abdelrahim
- Section of GI Oncology, Houston Methodist Neal Cancer Center and Cockrell Center for Advanced Therapeutics, Houston Methodist Hospital, Houston, TX, USA
| | - Abdullah Esmail
- Section of GI Oncology, Houston Methodist Neal Cancer Center and Cockrell Center for Advanced Therapeutics, Houston Methodist Hospital, Houston, TX, USA
| | - Anup Kasi
- University of Kansas Medical Center, Kansas City, KS, USA
| | - Nestor F Esnaola
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | | | | | - Benjamin A Weinberg
- Ruesch Center for the Cure of Gastrointestinal Cancers, Lombardi Comprehensive Cancer, Georgetown University Medical Center, Washington, DC, USA.
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11
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Imamura H, Tomimaru Y, Kobayashi S, Yamada D, Noda T, Takahashi H, Doki Y, Eguchi H. Diagnostic impact of postoperative CA19-9 dynamics on pancreatic cancer recurrence: a single-institution retrospective study. Updates Surg 2024; 76:479-486. [PMID: 38349569 DOI: 10.1007/s13304-024-01758-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 01/08/2024] [Indexed: 04/05/2024]
Abstract
Postoperative CA19-9 elevation after pancreatic cancer resection suggests recurrence but can also occur in benign conditions. This study aimed to investigate the interpretation of postoperative CA19-9 elevation after pancreatic cancer surgery in terms of cancer recurrence. A cohort of patients undergoing pancreatectomy for pancreatic cancer at our hospital was included. Among them, 52 patients exhibited postoperative CA19-9 elevation without radiological evidence of recurrence. These patients were evaluated with follow-up CA19-9 measurements. The CA19-9 increase rates were calculated based on the first elevation and the follow-up measurement. The association between the CA19-9 increase rate and tumor recurrence was assessed. Patients with a CA19-9 increase rate of ≥ 30% had a significantly higher frequency of recurrence within 3 months compared to those without such an increase (p = 0.0002). Multivariate analysis demonstrated that a CA19-9 increase rate of ≥ 30% was an independent risk factor for recurrence (odds ratio 8.17, p = 0.0309). The CA19-9 value at the first elevation (p = 0.1794) and at the follow-up measurement (p = 0.1121) were not associated with recurrence. After the first postoperative CA19-9 elevation, the CA19-9 increase rate based on follow-up measurements can serve as a predictive factor for tumor recurrence.
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Affiliation(s)
- Hiroki Imamura
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka E-2, Suita, Osaka, 565-0871, Japan
| | - Yoshito Tomimaru
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka E-2, Suita, Osaka, 565-0871, Japan
| | - Shogo Kobayashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka E-2, Suita, Osaka, 565-0871, Japan.
| | - Daisaku Yamada
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka E-2, Suita, Osaka, 565-0871, Japan
| | - Takehiro Noda
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka E-2, Suita, Osaka, 565-0871, Japan
| | - Hidenori Takahashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka E-2, Suita, Osaka, 565-0871, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka E-2, Suita, Osaka, 565-0871, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka E-2, Suita, Osaka, 565-0871, Japan
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12
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van Oosten AF, Groot VP, Dorland G, Burkhart RA, Wolfgang CL, van Santvoort HC, He J, Molenaar IQ, Daamen LA. Dynamics of Serum CA19-9 in Patients Undergoing Pancreatic Cancer Resection. Ann Surg 2024; 279:493-500. [PMID: 37389896 DOI: 10.1097/sla.0000000000005977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
BACKGROUND Carbohydrate antigen (CA) 19-9 is an established perioperative prognostic biomarker for pancreatic ductal adenocarcinoma (PDAC). However, it is unclear how CA19-9 monitoring should be used during postoperative surveillance to detect recurrence and to guide the initiation of recurrence-focused therapy. OBJECTIVE This study aimed to elucidate the value of CA19-9 as a diagnostic biomarker for disease recurrence in patients who underwent PDAC resection. METHODS Serum CA19-9 levels at diagnosis, after surgery, and during postoperative follow-up were analyzed in patients who underwent PDAC resection. All patients with at least two postoperative follow-up CA19-9 measurements before recurrence were included. Patients deemed to be nonsecretors of CA19-9 were excluded. The relative increase in postoperative CA19-9 was calculated for each patient by dividing the maximum postoperative CA19-9 value by the first postoperative value. Receiver operating characteristic analysis was performed to identify the optimal threshold for the relative increase in CA19-9 levels to identify recurrence in the training set using Youden's index. The performance of this cutoff was validated in a test set by calculating the area under the curve (AUC) and was compared to the performance of the optimal cutoff for postoperative CA19-9 measurements as a continuous value. In addition, sensitivity, specificity, and predictive values were assessed. RESULTS In total, 271 patients were included, of whom 208 (77%) developed recurrence. Receiver operating characteristic analysis demonstrated that a relative increase in postoperative serum CA19-9 of 2.6× was predictive of recurrence, with 58% sensitivity, 83% specificity, 95% positive predictive value, and 28% negative predictive value. The AUC for a 2.6× relative increase in the CA19-9 level was 0.719 in the training set and 0.663 in the test set. The AUC of postoperative CA19-9 as a continuous value (optimal threshold, 52) was 0.671 in the training set. In the training set, the detection of a 2.6-fold increase in CA19-9 preceded the detection of recurrence by a mean difference of 7 months ( P <0.001) and in the test set by 10 months ( P <0.001). CONCLUSIONS A relative increase in the postoperative serum CA19-9 level of 2.6-fold is a stronger predictive marker for recurrence than a continuous CA19-9 cutoff. A relative CA19-9 increase can precede the detection of recurrence on imaging for up to 7 to 10 months. Therefore, CA19-9 dynamics can be used as a biomarker to guide the initiation of recurrence-focused treatment.
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Affiliation(s)
- A Floortje van Oosten
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Vincent P Groot
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Galina Dorland
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital, Nieuwegein, The Netherlands
| | - R A Burkhart
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Jin He
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Lois A Daamen
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital, Nieuwegein, The Netherlands
- Division of Imaging and Oncology, University Medical Center Utrecht Cancer Center, Utrecht University, Utrecht, The Netherlands
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13
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Mun NE, Tran TKC, Park DH, Im JH, Park JI, Le TD, Moon YJ, Kwon SY, Yoo SW. Endoscopic Hyperspectral Imaging System to Discriminate Tissue Characteristics in Tissue Phantom and Orthotopic Mouse Pancreatic Tumor Model. Bioengineering (Basel) 2024; 11:208. [PMID: 38534482 DOI: 10.3390/bioengineering11030208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 02/15/2024] [Accepted: 02/21/2024] [Indexed: 03/28/2024] Open
Abstract
In this study, we developed an endoscopic hyperspectral imaging (eHSI) system and evaluated its performance in analyzing tissues within tissue phantoms and orthotopic mouse pancreatic tumor models. Our custom-built eHSI system incorporated a liquid crystal tunable filter. To assess its tissue discrimination capabilities, we acquired images of tissue phantoms, distinguishing between fat and muscle regions. The system underwent supervised training using labeled samples, and this classification model was then applied to other tissue phantom images for evaluation. In the tissue phantom experiment, the eHSI effectively differentiated muscle from fat and background tissues. The precision scores regarding fat tissue classification were 98.3% for the support vector machine, 97.7% for the neural network, and 96.0% with a light gradient-boosting machine algorithm, respectively. Furthermore, we applied the eHSI system to identify tumors within an orthotopic mouse pancreatic tumor model. The F-score of each pancreatic tumor-bearing model reached 73.1% for the KPC tumor model and 63.1% for the Pan02 tumor models. The refined imaging conditions and optimization of the fine-tuning of classification algorithms enhance the versatility and diagnostic efficacy of eHSI in biomedical applications.
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Affiliation(s)
- Na Eun Mun
- Department of Nuclear Medicine, Chonnam National University Medical School and Hwasun Hospital, Hwasun-gun 58128, Republic of Korea
- Institute for Molecular Imaging and Theranostics, Chonnam National University Medical School, Hwasun-gun 58128, Republic of Korea
| | - Thi Kim Chi Tran
- Institute for Molecular Imaging and Theranostics, Chonnam National University Medical School, Hwasun-gun 58128, Republic of Korea
- Biomedical Science Graduate Program, Chonnam National University, Hwasun-gun 58128, Republic of Korea
| | - Dong Hui Park
- Department of Nuclear Medicine, Chonnam National University Medical School and Hwasun Hospital, Hwasun-gun 58128, Republic of Korea
- Institute for Molecular Imaging and Theranostics, Chonnam National University Medical School, Hwasun-gun 58128, Republic of Korea
| | - Jin Hee Im
- Department of Nuclear Medicine, Chonnam National University Medical School and Hwasun Hospital, Hwasun-gun 58128, Republic of Korea
- Institute for Molecular Imaging and Theranostics, Chonnam National University Medical School, Hwasun-gun 58128, Republic of Korea
| | - Jae Il Park
- Department of Nuclear Medicine, Chonnam National University Medical School and Hwasun Hospital, Hwasun-gun 58128, Republic of Korea
- Institute for Molecular Imaging and Theranostics, Chonnam National University Medical School, Hwasun-gun 58128, Republic of Korea
| | - Thanh Dat Le
- Institute for Molecular Imaging and Theranostics, Chonnam National University Medical School, Hwasun-gun 58128, Republic of Korea
- Department of Artificial Intelligence Convergence, Chonnam National University, Gwangju 61186, Republic of Korea
| | - Young Jin Moon
- Department of Nuclear Medicine, Chonnam National University Medical School and Hwasun Hospital, Hwasun-gun 58128, Republic of Korea
- Institute for Molecular Imaging and Theranostics, Chonnam National University Medical School, Hwasun-gun 58128, Republic of Korea
| | - Seong-Young Kwon
- Department of Nuclear Medicine, Chonnam National University Medical School and Hwasun Hospital, Hwasun-gun 58128, Republic of Korea
- Institute for Molecular Imaging and Theranostics, Chonnam National University Medical School, Hwasun-gun 58128, Republic of Korea
| | - Su Woong Yoo
- Department of Nuclear Medicine, Chonnam National University Medical School and Hwasun Hospital, Hwasun-gun 58128, Republic of Korea
- Institute for Molecular Imaging and Theranostics, Chonnam National University Medical School, Hwasun-gun 58128, Republic of Korea
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14
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Servin-Rojas M, Fong ZV, Fernandez-Del Castillo C, Ferrone CR, Lee H, Lopez-Verdugo F, Qiao G, Rocha-Castellanos DM, Lillemoe KD, Qadan M. Tumor Size Reduction and Serum Carbohydrate Antigen 19-9 Kinetics After Neoadjuvant FOLFIRINOX in Patients With Pancreatic Ductal Adenocarcinoma. Surgery 2024; 175:471-476. [PMID: 37949693 DOI: 10.1016/j.surg.2023.09.041] [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] [Received: 05/22/2023] [Revised: 08/03/2023] [Accepted: 09/26/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Changes in tumor size and serum carbohydrate antigen 19-9 are commonly reported markers used to assess response to neoadjuvant therapy in pancreatic ductal adenocarcinoma. We evaluated the impact of the percentual tumor size reduction and carbohydrate antigen 19-9 kinetics on resectability and response to neoadjuvant FOLFIRINOX. METHODS This was an institutional analysis of patients with non-metastatic (upfront resectable, borderline resectable, and locally advanced) pancreatic ductal adenocarcinoma who underwent neoadjuvant FOLFIRINOX. Resectability, pathologic response, disease recurrence, and overall survival were evaluated. RESULTS Among 193 patients who completed FOLFIRINOX, 60% underwent resection, and 91% were R0. Pathologically, complete, and near-complete responses were achieved in 4% and 40% of patients, respectively. Tumor size reduction (odds ratio 1.02 per 1%, P = .024) and normalization of carbohydrate antigen 19-9 (odds ratio 2.61, P = .035) were associated with increased odds of resectability. Concerning pathologic response, tumor size reduction (odds ratio 1.03 per 1%, P = .018) was associated with increased odds of a complete and near-complete response. Lastly, in resected patients, a postoperative increase in carbohydrate antigen 19-9 after prior normalization after neoadjuvant therapy were at an increased risk of recurrence (hazard ratio 9.58, P < .001) and worse survival (hazard ratio 10.4, P < .001) compared to patients who maintained normalization. CONCLUSION In patients with non-metastatic pancreatic ductal adenocarcinoma who underwent neoadjuvant therapy, tumor size reduction was a significant predictor of resectability and pathologic response, including complete and near complete responses, whereas serum carbohydrate antigen 19-9 normalization predicted resectability, disease recurrence, and survival. Patients with a postoperative carbohydrate antigen 19-9 rise after prior normalization after administration of neoadjuvant therapy were at an increased risk of recurrence and worse overall survival.
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Affiliation(s)
- Maximiliano Servin-Rojas
- Department of Surgery, Massachusetts General Hospital, Boston, MA. http://www.twitter.com/servinrojasmd
| | - Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital, Boston, MA. http://www.twitter.com/zhivenfongmd
| | | | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Boston, MA. http://www.twitter.com/cferronemd
| | - Hang Lee
- Department of Biostatistics, Massachusetts General Hospital, Boston, MA
| | - Fidel Lopez-Verdugo
- Department of Surgery, Massachusetts General Hospital, Boston, MA. http://www.twitter.com/fidel_lv
| | - Guoliang Qiao
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Dario M Rocha-Castellanos
- Department of Surgery, Massachusetts General Hospital, Boston, MA. http://www.twitter.com/dariorochamd
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Boston, MA.
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15
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Augustinus S, Broekman T, Creemers GJ, Daamen LA, van Dieren S, de Groot JWB, Cirkel GA, Homs MYV, van Laarhoven HWM, van Leeuwen L, Los M, Luelmo SAC, van Oijen MGH, Spierings LEAM, de Vos-Geelen J, Besselink MG, Wilmink JW. Timing of start of systemic treatment in patients with asymptomatic metastasized pancreatic cancer (TIMEPAN): a protocol of a multicenter prospective patient preference non-randomized trial. Acta Oncol 2023; 62:1973-1978. [PMID: 37897803 DOI: 10.1080/0284186x.2023.2273898] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 10/17/2023] [Indexed: 10/30/2023]
Affiliation(s)
- Simone Augustinus
- Amsterdam UMC, Department of Surgery, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Thijmen Broekman
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Amsterdam UMC, Department of Medical Oncology, University of Amsterdam, Amsterdam, The Netherlands
| | - Geert-Jan Creemers
- Department of Medical Oncology, Catherina Hospital, Eindhoven, The Netherlands
| | - Lois A Daamen
- Division of Imaging & Oncology, University Medical Center Utrecht Cancer Center, Utrecht University, Utrecht, The Netherlands
- Department of Surgery, University Medical Center Utrecht Cancer Center, St Antonius Hospital Nieuwegein, Regional Academic Cancer Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - Susan van Dieren
- Amsterdam UMC, Department of Surgery, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Geert A Cirkel
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, Meander Medisch Centrum, Amersfoort, The Netherlands
| | - Marjolein Y V Homs
- Department of Medical Oncology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Hanneke W M van Laarhoven
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Amsterdam UMC, Department of Medical Oncology, University of Amsterdam, Amsterdam, The Netherlands
| | - Lobke van Leeuwen
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, Diakonessenhuis, Utrecht, The Netherlands
| | - Maartje Los
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, St. Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | - Saskia A C Luelmo
- Department of Medical Oncology, Leids Universitair Medisch Centrum, Leiden, The Netherlands
| | - Martijn G H van Oijen
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Amsterdam UMC, Department of Medical Oncology, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Judith de Vos-Geelen
- Department of Medical Oncology, GROW, Maastricht UMC, Maastsricht, The Netherlands
| | - Marc G Besselink
- Amsterdam UMC, Department of Surgery, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Johanna W Wilmink
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Amsterdam UMC, Department of Medical Oncology, University of Amsterdam, Amsterdam, The Netherlands
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16
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Augustinus S, van Laarhoven HWM, Cirkel GA, de Groot JWB, Groot Koerkamp B, Macarulla T, Melisi D, O’Reilly EM, van Santvoort HC, Mackay TM, Besselink MG, Wilmink JW. Timing of Initiation of Palliative Chemotherapy in Asymptomatic Patients with Metastatic Pancreatic Cancer: An International Expert Survey and Case-Vignette Study. Cancers (Basel) 2023; 15:5603. [PMID: 38067306 PMCID: PMC10705283 DOI: 10.3390/cancers15235603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 11/17/2023] [Accepted: 11/20/2023] [Indexed: 02/15/2024] Open
Abstract
Background: The use of imaging, in general, and during follow-up after resection of pancreatic cancer, is increasing. Consequently, the number of asymptomatic patients diagnosed with metastatic pancreatic cancer (mPDAC) is increasing. In these patients, palliative systemic therapy is the only tumor-directed treatment option; hence, it is often immediately initiated. However, delaying therapy in asymptomatic palliative patients may preserve quality of life and avoid therapy-related toxicity, but the impact on survival is unknown. This study aimed to gain insight into the current perspectives and clinical decision=making of experts regarding the timing of treatment initiation of patients with asymptomatic mPDAC. Methods: An online survey (13 questions, 9 case-vignettes) was sent to all first and last authors of published clinical trials on mPDAC over the past 10 years and medical oncologists of the Dutch Pancreatic Cancer Group. Inter-rater variability was determined using the Kappa Light test. Differences in the preferred timing of treatment initiation among countries, continents, and years of experience were analyzed using Fisher's exact test. Results: Overall, 78 of 291 (27%) medical oncologists from 15 countries responded (62% from Europe, 23% from North America, and 15% from Asia-Pacific). The majority of respondents (63%) preferred the immediate initiation of chemotherapy following diagnosis. In 3/9 case-vignettes, delayed treatment was favored in specific clinical contexts (i.e., patient with only one small lung metastasis, significant comorbidities, and higher age). A significant degree of inter-rater variability was present within 7/9 case-vignettes. The recommended timing of treatment initiation differed between continents for 2/9 case-vignettes (22%), in 7/9 (77.9%) comparing the Netherlands with other countries, and based on years of experience for 5/9 (56%). Conclusions: Although the response rate was limited, in asymptomatic patients with mPDAC, immediate treatment is most often preferred. Delaying treatment until symptoms occur is considered in patients with limited metastatic disease, more comorbidities, and higher age.
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Affiliation(s)
- Simone Augustinus
- Department of Surgery, Location University of Amsterdam, Amsterdam University Medical Center, 1105 Amsterdam, The Netherlands; (S.A.); (M.G.B.)
- Cancer Center Amsterdam, 1105 Amsterdam, The Netherlands
| | - Hanneke W. M. van Laarhoven
- Cancer Center Amsterdam, 1105 Amsterdam, The Netherlands
- Department of Medical Oncology, Location University of Amsterdam, Amsterdam University Medical Center, 1105 Amsterdam, The Netherlands
| | - Geert A. Cirkel
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, 3584 Utrecht, The Netherlands
| | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, 3015 Rotterdam, The Netherlands
| | - Teresa Macarulla
- Department of Medical Oncology, Vall d’Hebron Unveristy Hospital, Vall d’Hebron Institute of Oncology (VHIO), 08035 Barcelona, Spain
| | - Davide Melisi
- Digestive Molecular Clinical Oncology Unit, Univeristy of Verona, 37134 Verona, Italy
| | - Eileen M. O’Reilly
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Hjalmar C. van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center, St. Antonius Hospital Nieuwegein, Utrecht University, 3584 Utrech, The Netherlands
| | - Tara M. Mackay
- Department of Surgery, Location University of Amsterdam, Amsterdam University Medical Center, 1105 Amsterdam, The Netherlands; (S.A.); (M.G.B.)
- Cancer Center Amsterdam, 1105 Amsterdam, The Netherlands
| | - Marc G. Besselink
- Department of Surgery, Location University of Amsterdam, Amsterdam University Medical Center, 1105 Amsterdam, The Netherlands; (S.A.); (M.G.B.)
- Cancer Center Amsterdam, 1105 Amsterdam, The Netherlands
| | - Johanna W. Wilmink
- Cancer Center Amsterdam, 1105 Amsterdam, The Netherlands
- Department of Medical Oncology, Location University of Amsterdam, Amsterdam University Medical Center, 1105 Amsterdam, The Netherlands
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17
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Halle-Smith JM, Hall LA, Powell-Brett SF, Merali N, Frampton AE, Beggs AD, Moss P, Roberts KJ. Pancreatic Exocrine Insufficiency and the Gut Microbiome in Pancreatic Cancer: A Target for Future Diagnostic Tests and Therapies? Cancers (Basel) 2023; 15:5140. [PMID: 37958314 PMCID: PMC10649877 DOI: 10.3390/cancers15215140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/18/2023] [Accepted: 10/20/2023] [Indexed: 11/15/2023] Open
Abstract
Pancreatic exocrine insufficiency (PEI) is common amongst pancreatic cancer patients and is associated with poorer treatment outcomes. Pancreatic enzyme replacement therapy (PERT) is known to improve outcomes in pancreatic cancer, but the mechanisms are not fully understood. The aim of this narrative literature review is to summarise the current evidence linking PEI with microbiome dysbiosis, assess how microbiome composition may be impacted by PERT treatment, and look towards possible future diagnostic and therapeutic targets in this area. Early evidence in the literature reveals that there are complex mechanisms by which pancreatic secretions modulate the gut microbiome, so when these are disturbed, as in PEI, gut microbiome dysbiosis occurs. PERT has been shown to return the gut microbiome towards normal, so called rebiosis, in animal studies. Gut microbiome dysbiosis has multiple downstream effects in pancreatic cancer such as modulation of the immune response and the response to chemotherapeutic agents. It therefore represents a possible future target for future therapies. In conclusion, it is likely that the gut microbiome of pancreatic cancer patients with PEI exhibits dysbiosis and that this may potentially be reversible with PERT. However, further human studies are required to determine if this is indeed the case.
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Affiliation(s)
- James M. Halle-Smith
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK (K.J.R.)
- Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2GW, UK;
| | - Lewis A. Hall
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK (K.J.R.)
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
| | - Sarah F. Powell-Brett
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK (K.J.R.)
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
| | - Nabeel Merali
- Section of Oncology, Department of Clinical & Experimental Medicine, University of Surrey, Guildford GU2 7WG, UK (A.E.F.); (P.M.)
- Minimal Access Therapy Training Unit (MATTU), Leggett Building, University of Surrey, Guildford GU2 7WG, UK
- Department of Hepato-Pancreato-Biliary (HPB) Surgery, Royal Surrey County Hospital, Egerton Road, Guildford GU2 7XX, UK
| | - Adam E. Frampton
- Section of Oncology, Department of Clinical & Experimental Medicine, University of Surrey, Guildford GU2 7WG, UK (A.E.F.); (P.M.)
- Minimal Access Therapy Training Unit (MATTU), Leggett Building, University of Surrey, Guildford GU2 7WG, UK
- Department of Hepato-Pancreato-Biliary (HPB) Surgery, Royal Surrey County Hospital, Egerton Road, Guildford GU2 7XX, UK
| | - Andrew D. Beggs
- Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2GW, UK;
- Colorectal Surgery Department, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK
| | - Paul Moss
- Section of Oncology, Department of Clinical & Experimental Medicine, University of Surrey, Guildford GU2 7WG, UK (A.E.F.); (P.M.)
| | - Keith J. Roberts
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK (K.J.R.)
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
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18
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Eijkelenkamp H, Grimbergen G, Daamen LA, Heerkens HD, van de Ven S, Mook S, Meijer GJ, Molenaar IQ, van Santvoort HC, Paulson E, Erickson BA, Verkooijen HM, Hall WA, Intven MPW. Clinical outcomes after online adaptive MR-guided stereotactic body radiotherapy for pancreatic tumors on a 1.5 T MR-linac. Front Oncol 2023; 13:1040673. [PMID: 37854684 PMCID: PMC10579578 DOI: 10.3389/fonc.2023.1040673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 08/18/2023] [Indexed: 10/20/2023] Open
Abstract
Introduction Online adaptive magnetic resonance-guided radiotherapy (MRgRT) is a promising treatment modality for pancreatic cancer and is being employed by an increasing number of centers worldwide. However, clinical outcomes have only been reported on a small scale, often from single institutes and in the context of clinical trials, in which strict patient selection might limit generalizability of outcomes. This study presents clinical outcomes of a large, international cohort of patients with (peri)pancreatic tumors treated with online adaptive MRgRT. Methods We evaluated clinical outcomes and treatment details of patients with (peri)pancreatic tumors treated on a 1.5 Tesla (T) MR-linac in two large-volume treatment centers participating in the prospective MOMENTUM cohort (NCT04075305). Treatments were evaluated through schematics, dosage, delivery strategies, and success rates. Acute toxicity was assessed until 3 months after MRgRT started, and late toxicity from 3-12 months of follow-up (FU). The EORTC QLQ-C30 questionnaire was used to evaluate the quality of life (QoL) at baseline and 3 months of FU. Furthermore, we used the Kaplan-Meier analysis to calculate the cumulative overall survival. Results A total of 80 patients were assessed with a median FU of 8 months (range 1-39 months). There were 34 patients who had an unresectable primary tumor or were medically inoperable, 29 who had an isolated local recurrence, and 17 who had an oligometastasis. A total of 357 of the 358 fractions from all hypofractionated schemes were delivered as planned. Grade 3-4 acute toxicity occurred in 3 of 59 patients (5%) with hypofractionated MRgRT and grade 3-4 late toxicity in 5 of 41 patients (12%). Six patients died within 3 months after MRgRT; in one of these patients, RT attribution could not be ruled out as cause of death. The QLQ-C30 global health status remained stable from baseline to 3 months FU (70.5 at baseline, median change of +2.7 [P = 0.5]). The 1-year cumulative overall survival for the entire cohort was 67%, and that for the primary tumor group was 66%. Conclusion Online adaptive MRgRT for (peri)pancreatic tumors on a 1.5 T MR-Linac could be delivered as planned, with low numbers of missed fractions. In addition, treatments were associated with limited grade 3-4 toxicity and a stable QoL at 3 months of FU.
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Affiliation(s)
- Hidde Eijkelenkamp
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Guus Grimbergen
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Lois A. Daamen
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Hanne D. Heerkens
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
- Department of Radiotherapy, Radboud University Medical Center, Nijmegen, Netherlands
| | - Saskia van de Ven
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Stella Mook
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Gert J. Meijer
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Izaak Q. Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht, Netherlands
| | | | - Eric Paulson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Beth Ann Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | | | - William Adrian Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Martijn P. W. Intven
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
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19
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Sickels A, Jain T, Dudeja V. Peritoneal Cell-Free DNA: A Novel Biomarker for Recurrence in Pancreatic Cancer. Ann Surg Oncol 2023; 30:6308-6310. [PMID: 37482596 DOI: 10.1245/s10434-023-13947-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 07/03/2023] [Indexed: 07/25/2023]
Affiliation(s)
- Angela Sickels
- Division of Surgical Oncology, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Tejeshwar Jain
- Division of Surgical Oncology, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Vikas Dudeja
- Division of Surgical Oncology, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
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20
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Sumiyoshi T, Uemura K, Shintakuya R, Okada K, Otsuka H, Baba K, Serikawa M, Ishii Y, Tsuboi T, Arihiro K, Murakami Y, Murashita J, Takahashi S. Prognostic factor in patient with recurrent pancreatic adenocarcinoma. Langenbecks Arch Surg 2023; 408:347. [PMID: 37658871 DOI: 10.1007/s00423-023-03073-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 08/17/2023] [Indexed: 09/05/2023]
Abstract
PURPOSE To elucidate prognostic factors for post-recurrence survival in patients with pancreatic ductal adenocarcinoma (PDAC). METHODS Patients who underwent curative-intent surgery for PDAC between January 2014 and May 2020 were identified. Among them, patients who had postoperative recurrences and received chemotherapy were retrospectively investigated. Independent prognostic factors for survival after recurrence were investigated using multivariate analyses. Eligible patients were divided into two groups according to the presence or absence of the identified prognostic factors, and survival times after recurrence were compared. RESULTS Eighty-four patients with recurrent PDAC were included. Multivariate analysis showed that red blood cell (RBC) transfusion (HR, 2.80; p = 0.0051), low albumin level (HR, 1.84; p = 0.0402), and high carbohydrate antigen 19-9 (CA19-9) level at recurrence (HR, 2.11; p = 0.0258) were significant predictors of shorter survival after recurrence. The median survival times after recurrence in the transfusion and non-transfusion groups were 5.5 vs. 18.1 months (p < 0.0001), respectively; those in the low and normal albumin groups were 10.1 vs. 18.7 months (p = 0.0049), and those in the high and normal CA19-9 groups were 11.5 vs. 22.6 months (p = 0.0023), respectively. CONCLUSIONS RBC transfusion, low albumin, and high CA19-9 levels at recurrence negatively affected survival after recurrence in patients with PDAC.
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Affiliation(s)
- Tatsuaki Sumiyoshi
- Department of Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Kenichiro Uemura
- Department of Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan.
| | - Ryuta Shintakuya
- Department of Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Kenjiro Okada
- Department of Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Hiroyuki Otsuka
- Department of Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Kenta Baba
- Department of Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Masahiro Serikawa
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Yasutaka Ishii
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Tomofumi Tsuboi
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Koji Arihiro
- Department of Anatomical Pathology, Hiroshima University, Hiroshima, Japan
| | - Yoshiaki Murakami
- Digestive Disease Center, Hiroshima Memorial Hospital, Hiroshima, Japan
| | | | - Shinya Takahashi
- Department of Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
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21
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Xia T, Xu P, Mou Y, Zhang X, Song S, Zhou Y, Lu C, Zhu Q, Xu Y, Jin W, Wang Y. Factors predicting recurrence after left‑sided pancreatectomy for pancreatic ductal adenocarcinoma. World J Surg Oncol 2023; 21:191. [PMID: 37349737 DOI: 10.1186/s12957-023-03080-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 06/17/2023] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND Recurrence after resection is the main factor for poor survival. The relationship between clinicopathological factors and recurrence after curative distal pancreatectomy for PDAC has rarely been reported separately. METHODS Patients with PDAC after left‑sided pancreatectomy between May 2015 and August 2021 were retrospectively identified. RESULTS One hundred forty-one patients were included. Recurrence was observed in 97 patients (68.8%), while 44 (31.2%) patients had no recurrence. The median RFS was 8.8 months. The median OS was 24.9 months. Local recurrence was the predominant first detected recurrence site (n = 36, 37.1%), closely followed by liver recurrence (n = 35, 36.1%). Multiple recurrences occurred in 16 (16.5%) patients, peritoneal recurrence in 6 (6.2%) patients, and lung recurrence in 4 (4.1%) patients. High CA19-9 value after surgery, poor differentiation grade, and positive lymph nodes were found to be independently associated with recurrence. The patients receiving adjuvant chemotherapy had a decreased likelihood of recurrence. In the high CA19-9 value cohort, the median PFS and OS of the patients with or without chemotherapy were 8.0 VS. 5.7 months and 15.6 VS. 13.8 months, respectively. In the normal CA19-9 value cohort, there was no significant difference in PFS with or without chemotherapy (11.7 VS. 10.0 months, P = 0.147). However, OS was significantly longer in the patients with chemotherapy (26.4 VS. 13.8 months, P = 0.019). CONCLUSIONS Tumor biologic characteristics, such as T stage, tumor differentiation and positive lymph nodes, affecting CA19-9 value after surgery are associated with patterns and timing of recurrence. Adjuvant chemotherapy significantly reduced recurrence and improved survival. Chemotherapy is strongly recommended in patients with high CA199 after surgery.
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Affiliation(s)
- Tao Xia
- Department of General Surgery, Cancer Center, Division of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, China.
| | - Peng Xu
- Department of General Surgery, Cancer Center, Division of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, China
- Department of Surgery, Qingdao University, Qingdao, China
| | - Yiping Mou
- Department of General Surgery, Cancer Center, Division of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, China.
- Department of Surgery, Qingdao University, Qingdao, China.
- Department of Surgery, Wenzhou Medical University, Wenzhou, China.
| | - Xizhou Zhang
- Department of General Surgery, Cancer Center, Division of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, China
| | - Shihao Song
- Department of General Surgery, Cancer Center, Division of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, China
- Department of Surgery, Wenzhou Medical University, Wenzhou, China
| | - Yucheng Zhou
- Department of General Surgery, Cancer Center, Division of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, China
| | - Chao Lu
- Department of General Surgery, Cancer Center, Division of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, China
| | - Qicong Zhu
- Department of General Surgery, Cancer Center, Division of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, China
| | - Yunyun Xu
- Department of General Surgery, Cancer Center, Division of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, China
| | - Weiwei Jin
- Department of General Surgery, Cancer Center, Division of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, China
| | - Yuanyu Wang
- Department of General Surgery, Cancer Center, Division of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, China
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22
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Malleo G, Maggino L, Lionetto G, Patton A, Paiella S, Pea A, Esposito A, Casetti L, Luchini C, Scarpa A, Bassi C, Salvia R. A dynamic analysis of empirical survival outcomes after pancreatectomy for pancreatic ductal adenocarcinoma. Surgery 2023; 173:1030-1038. [PMID: 36585320 DOI: 10.1016/j.surg.2022.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 10/18/2022] [Accepted: 11/15/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Survival outcomes after pancreatectomy for pancreatic ductal adenocarcinoma may be biased by right-censoring. We herein analyzed a large dataset with no censored events for up to 5 years and dynamically investigated the impact of known prognostic factors, accounting for unobserved tumor characteristics. METHODS Consecutive patients undergoing pancreatectomy from 2000 to July 2015 were included. The 1- to 5-year empirical survival rates were calculated, and factors associated with long-term survival (≥5 years) were analyzed using multivariable models. Dynamic analyses of survival and recurrence were conducted through landmarking, and the contribution of unobserved heterogeneity was estimated using frailty models. RESULTS The study population included 1,048 patients. The median follow-up was 30.4 months in the whole cohort and 97.2 months in survivors. The median survival was 30.4 months, with empirical 1- to 5-year rates of 85.5%, 59.6%, 43.2%, 32.1%, and 27.5%. A favorable pathological profile was associated with 5-year survival, albeit 25.7% of long-survivors received an R1 resection, and 28.8% had N2 disease. The median recurrence-free survival was 17.2 months. At landmark analyses, baseline prognostic lost strength over time, with no independent predictors of survival being identified in the sets of patients alive at 4 and 5 years. There was a significant amount of unobserved heterogeneity in the early postoperative period. CONCLUSION The 5-year post-pancreatectomy empirical survival was 27.5%. Dynamic analyses showed a time-varying structure of prognostic variables and a substantial impact of unobserved tumor characteristics that may drive the disease course under the selective pressure of surgical resection and adjuvant chemotherapy.
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Affiliation(s)
- Giuseppe Malleo
- Unit of General and Pancreatic Surgery, University of Verona, Italy. https://twitter.com/gimalleo
| | - Laura Maggino
- Unit of General and Pancreatic Surgery, University of Verona, Italy. https://twitter.com/LMaggino
| | | | - Alex Patton
- Unit of General and Pancreatic Surgery, University of Verona, Italy
| | - Salvatore Paiella
- Unit of General and Pancreatic Surgery, University of Verona, Italy. https://twitter.com/Totuccio1983
| | - Antonio Pea
- Unit of General and Pancreatic Surgery, University of Verona, Italy. https://twitter.com/peaantonio1
| | | | - Luca Casetti
- Unit of General and Pancreatic Surgery, University of Verona, Italy
| | - Claudio Luchini
- Section of Pathology, Department of Pathology and Diagnostics, University of Verona, Italy. https://twitter.com/CLuchini10
| | - Aldo Scarpa
- Section of Pathology, Department of Pathology and Diagnostics, University of Verona, Italy
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, University of Verona, Italy
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, University of Verona, Italy.
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23
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Tumor Stroma Area and Other Prognostic Factors in Pancreatic Ductal Adenocarcinoma Patients Submitted to Surgery. Diagnostics (Basel) 2023; 13:diagnostics13040655. [PMID: 36832145 PMCID: PMC9955223 DOI: 10.3390/diagnostics13040655] [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: 01/25/2023] [Revised: 02/05/2023] [Accepted: 02/06/2023] [Indexed: 02/12/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) has a dense stroma, responsible for up to 80% of its volume. The amount of stroma can be associated with prognosis, although there are discrepancies regarding its concrete impact. The aim of this work was to study prognostic factors for PDAC patients submitted to surgery, including the prognostic impact of the tumor stroma area (TSA). A retrospective study with PDAC patients submitted for surgical resection was conducted. The TSA was calculated using QuPath-0.2.3 software. Arterial hypertension, diabetes mellitus, and surgical complications Clavien-Dindo>IIIa are independent risk factors for mortality in PDAC patients submitted to surgery. Regarding TSA, using >1.9 × 1011 µ2 as cut-off value for all stages, patients seem to have longer overall survival (OS) (31 vs. 21 months, p = 0.495). For stage II, a TSA > 2 × 1011 µ2 was significantly associated with an R0 resection (p = 0.037). For stage III patients, a TSA > 1.9 × 1011 µ2 was significantly associated with a lower histological grade (p = 0.031), and a TSA > 2E + 11 µ2 was significantly associated with a preoperative AP ≥ 120 U/L (p = 0.009) and a lower preoperative AST (≤35 U/L) (p = 0.004). Patients with PDAC undergoing surgical resection with preoperative CA19.9 > 500 U/L and AST ≥ 100 U/L have an independent higher risk of recurrence. Tumor stroma could have a protective effect in these patients. A larger TSA is associated with an R0 resection in stage II patients and a lower histological grade in stage III patients, which may contribute to a longer OS.
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24
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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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25
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Conroy T, Castan F, Lopez A, Turpin A, Ben Abdelghani M, Wei AC, Mitry E, Biagi JJ, Evesque L, Artru P, Lecomte T, Assenat E, Bauguion L, Ychou M, Bouché O, Monard L, Lambert A, Hammel P. Five-Year Outcomes of FOLFIRINOX vs Gemcitabine as Adjuvant Therapy for Pancreatic Cancer: A Randomized Clinical Trial. JAMA Oncol 2022; 8:1571-1578. [PMID: 36048453 PMCID: PMC9437831 DOI: 10.1001/jamaoncol.2022.3829] [Citation(s) in RCA: 109] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/29/2022] [Indexed: 01/11/2023]
Abstract
Importance Early results at 3 years from the PRODIGE 24/Canadian Cancer Trials Group PA6 randomized clinical trial showed survival benefits with adjuvant treatment with modified FOLFIRINOX vs gemcitabine in patients with resected pancreatic ductal adenocarcinoma; mature data are now available. Objective To report 5-year outcomes and explore prognostic factors for overall survival. Design, Setting, and Participants This open-label, phase 3 randomized clinical trial was conducted at 77 hospitals in France and Canada and included patients aged 18 to 79 years with histologically confirmed pancreatic ductal adenocarcinoma who had undergone complete macroscopic (R0/R1) resection within 3 to 12 weeks before randomization. Patients were included from April 16, 2012, through October 3, 2016. The cutoff date for this analysis was June 28, 2021. Interventions A total of 493 patients were randomized (1:1) to receive treatment with modified FOLFIRINOX (oxaliplatin, 85 mg/m2 of body surface area; irinotecan, 150-180 mg/m2; leucovorin, 400 mg/m2; and fluorouracil, 2400 mg/m2, every 2 weeks) or gemcitabine (1000 mg/m2, days 1, 8, and 15, every 4 weeks) as adjuvant therapy for 24 weeks. Main Outcomes and Measures Primary end point was disease-free survival. Secondary end points included overall survival, metastasis-free survival, and cancer-specific survival. Prognostic factors for overall survival were determined. Results Of the 493 patients, 216 (43.8%) were women, and the mean (SD) age was 62.0 (8.9) years. At a median of 69.7 months' follow-up, 367 disease-free survival events were observed. In patients receiving chemotherapy with modified FOLFIRINOX vs gemcitabine, median disease-free survival was 21.4 months (95% CI, 17.5-26.7) vs 12.8 months (95% CI, 11.6-15.2) (hazard ratio [HR], 0.66; 95% CI, 0.54-0.82; P < .001) and 5-year disease-free survival was 26.1% vs 19.0%; median overall survival was 53.5 months (95% CI, 43.5-58.4) vs 35.5 months (95% CI, 30.1-40.3) (HR, 0.68; 95% CI, 0.54-0.85; P = .001), and 5-year overall survival was 43.2% vs 31.4%; median metastasis-free survival was 29.4 months (95% CI, 21.4-40.1) vs 17.7 months (95% CI, 14.0-21.2) (HR, 0.64; 95% CI, 0.52-0.80; P < .001); and median cancer-specific survival was 54.7 months (95% CI, 45.8-68.4) vs 36.3 months (95% CI, 30.5-43.9) (HR, 0.65; 95% CI, 0.51-0.82; P < .001). Multivariable analysis identified modified FOLFIRINOX, age, tumor grade, tumor staging, and larger-volume center as significant favorable prognostic factors for overall survival. Shorter relapse delay was an adverse prognostic factor. Conclusions and Relevance The final 5-year results from the PRODIGE 24/Canadian Cancer Trials Group PA6 randomized clinical trial indicate that adjuvant treatment with modified FOLFIRINOX yields significantly longer survival than gemcitabine in patients with resected pancreatic ductal adenocarcinoma. Trial Registration EudraCT: 2011-002026-52; ClinicalTrials.gov Identifier: NCT01526135.
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Affiliation(s)
- Thierry Conroy
- Medical Oncology department, Institut de cancérologie de Lorraine, Vandoeuvre-lès-Nancy, France and Université de Lorraine, APEMAC, équipe MICS, Nancy, France
| | - Florence Castan
- Biometry Department, ICM Regional Cancer Institute of Montpellier, Montpellier, France and Montpellier University, Montpellier, France
| | - Anthony Lopez
- Hepatogastroenterology department, University Hospital, Nancy, France
| | - Anthony Turpin
- Medical Oncology Department, University hospital, Lille, France and University of Lille, Lille, France
| | | | - Alice C. Wei
- Surgery department, Princess Margaret Hospital, Toronto, Ontario, Canada
| | - Emmanuel Mitry
- Medical Oncology department, Institut Paoli-Calmettes, Marseille, France
| | | | - Ludovic Evesque
- Medical oncology department, Centre Antoine-Lacassagne, Nice, France
| | - Pascal Artru
- Hepatogastroenterology department, Hôpital Jean-Mermoz, Lyon, France
| | - Thierry Lecomte
- Hepatogastroenterology department, Hôpital Trousseau, Tours, France and INSERM UMR 6239, Tours University, Tours, France
| | - Eric Assenat
- Medical oncology department, Centre Hospitalier Universitaire de Saint-Eloi, Montpellier, France
| | - Lucile Bauguion
- Hepatogastroenterology department, Centre Hospitalier Départemental Vendée, La Roche-sur-Yon, France
| | - Marc Ychou
- Oncology department, ICM Regional Cancer Institute of Montpellier, Montpellier, France and Montpellier University, Montpellier, France
| | - Olivier Bouché
- Digestive oncology department, Centre Hospitalier Universitaire Robert Debré, Reims, France
| | | | - Aurélien Lambert
- Medical Oncology department, Institut de cancérologie de Lorraine, Vandoeuvre-lès-Nancy, France and Université de Lorraine, APEMAC, équipe MICS, Nancy, France
| | - Pascal Hammel
- Digestive and Medical Oncology department, Hôpital Paul Brousse and University Paris-Saclay, Villejuif, France
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26
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van Goor IWJM, Daamen LA, Besselink MG, Bruynzeel AME, Busch OR, Cirkel GA, Groot Koerkamp B, Haj Mohammed N, Heerkens HD, van Laarhoven HWM, Meijer GJ, Nuyttens J, van Santvoort HC, van Tienhoven G, Verkooijen HM, Wilmink JW, Molenaar IQ, Intven MPW. A nationwide randomized controlled trial on additional treatment for isolated local pancreatic cancer recurrence using stereotactic body radiation therapy (ARCADE). Trials 2022; 23:913. [PMID: 36307892 PMCID: PMC9617359 DOI: 10.1186/s13063-022-06829-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/06/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Disease recurrence is the main cause of mortality after resection of pancreatic ductal adenocarcinoma (PDAC). In 20-30% of resected patients, isolated local PDAC recurrence occurs. Retrospective studies have suggested that stereotactic body radiation therapy (SBRT) might lead to improved local control in these patients, potentially having a beneficial effect on both survival and quality of life. The "nationwide randomized controlled trial on additional treatment for isolated local pancreatic cancer recurrence using stereotactic body radiation therapy" (ARCADE) will investigate the value of SBRT in addition to standard of care in patients with isolated local PDAC recurrence compared to standard of care alone, regarding both survival and quality of life outcomes. METHODS The ARCADE trial is nested within a prospective cohort (Dutch Pancreatic Cancer Project; PACAP) according to the 'Trials within Cohorts' design. All PACAP participants with isolated local PDAC recurrence after primary resection who provided informed consent for being randomized in future studies are eligible. Patients will be randomized for local therapy (5 fractions of 8 Gy SBRT) in addition to standard of care or standard of care alone. In total, 174 patients will be included. The main study endpoint is survival after recurrence. The most important secondary endpoint is quality of life. DISCUSSION It is hypothesized that additional SBRT, compared to standard of care alone, improves survival and quality of life in patients with isolated local recurrence after PDAC resection. TRIAL REGISTRATION ClinicalTrials.gov registration NCT04881487 . Registered on May 11, 2021.
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Affiliation(s)
- I W J M van Goor
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands.
- Department of Radiation Oncology, Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands.
| | - L A Daamen
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands
- Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - M G Besselink
- Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - A M E Bruynzeel
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Radiation Oncology, Amsterdam University Medical Center, location Vrije Universiteit, Amsterdam, the Netherlands
| | - O R Busch
- Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - G A Cirkel
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands
| | - B Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - N Haj Mohammed
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands
| | - H D Heerkens
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - H W M van Laarhoven
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Medical Oncology, Amsterdam University Medical Center, location University of Amsterdam, Amsterdam, the Netherlands
| | - G J Meijer
- Department of Radiation Oncology, Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands
| | - J Nuyttens
- Department of Radiation Oncology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - H C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands
| | - G van Tienhoven
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Radiation Oncology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - H M Verkooijen
- Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - J W Wilmink
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Medical Oncology, Amsterdam University Medical Center, location University of Amsterdam, Amsterdam, the Netherlands
| | - I Q Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands
| | - M P W Intven
- Department of Radiation Oncology, Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands.
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27
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Nauheim D, Moskal D, Renslo B, Chadwick M, Jiang W, Yeo CJ, Nevler A, Bowne W, Lavu H. KRAS mutation allele frequency threshold alters prognosis in right-sided resected pancreatic cancer. J Surg Oncol 2022; 126:314-321. [PMID: 35333412 DOI: 10.1002/jso.26860] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/18/2022] [Accepted: 03/05/2022] [Indexed: 12/17/2022]
Abstract
BACKGROUND Next-generation sequencing (NGS) provides information on genetic mutations and mutant allele frequency in tumor specimens. We investigated the prognostic significance of KRAS mutant allele frequency in patients with right-sided pancreatic ductal adenocarcinoma (PDAC) treated with surgical resection. METHODS A retrospective study reviewed patients who underwent surgical resection for PDAC and analyzed tumors with an in-house mutational panel. Microdissected samples were studied using an NGS-based assay to detect over 200 hotspot mutations in 42 genes (Pan42) commonly involved in PDAC. RESULTS A total of 144 PDAC right-sided surgical patients with a Pan42 panel were evaluated between 2015 and 2020; 121 patients (84%) harbored a KRAS mutation. Detected mutant allele frequencies were categorized as less than 20% (low mKRAS, n = 92) or greater than or equal to 20% (high mKRAS, n = 29). High mKRAS (KRAS ≥ 20%) patients were noted to have shorter disease-free survival after surgery (11.5 ± 2.1 vs. 19.5 ± 3.5 months, p = 0.03), more advanced tumor stage (p = 0.02), larger tumors (3.6 vs. 2.7 cm, p = 0.001), greater tumor cellularity (26% vs. 18%, p = 0.001), and higher rate of distant recurrence (p = 0.03) than low mKRAS patients. CONCLUSION This study demonstrates the importance of KRAS mutant allele frequency on pathological characteristics and prognosis in right-sided PDAC treated with surgery.
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Affiliation(s)
- David Nauheim
- Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - David Moskal
- Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Bryan Renslo
- Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Matthew Chadwick
- Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Wei Jiang
- Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Charles J Yeo
- Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Avinoam Nevler
- Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Wilbur Bowne
- Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Harish Lavu
- Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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28
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Einama T, Yamagishi Y, Takihata Y, Konno F, Kobayashi K, Yonamine N, Fujinuma I, Tsunenari T, Kouzu K, Nakazawa A, Iwasaki T, Shinto E, Ishida J, Ueno H, Kishi Y. Clinical Impact of Dual Time Point 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography Fusion Imaging in Pancreatic Cancer. Cancers (Basel) 2022; 14:cancers14153688. [PMID: 35954351 PMCID: PMC9367454 DOI: 10.3390/cancers14153688] [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: 05/15/2022] [Revised: 07/13/2022] [Accepted: 07/13/2022] [Indexed: 01/27/2023] Open
Abstract
We examined the value of preoperative dual time point (DTP) 18F-fluorodeoxyglucose positron emission tomography/computed tomography fusion imaging (FDG PET/CT) as a predictor of early recurrence or the outcomes in patients with pancreatic cancer. Standardized uptake values (SUVs) in DTP FDG PET/CT were performed as preoperative staging. SUVmax1 and SUVmax2 were obtained in 60 min and 120 min, respectively. ΔSUVmax% was defined as (SUVmax2 − SUVmax1)/SUVmax1 × 100. The optimal cut-off values for SUVmax parameters were selected based on tumor relapse within 1 year of surgery. Optimal cut-off values for SUVmax1 and ΔSUVmax% were 7.18 and 24.25, respectively. The combination of SUVmax1 and ΔSUVmax% showed higher specificity and sensitivity, and higher positive and negative predictive values for tumor relapse within 1 year than SUVmax1 alone. Relapse-free survival (RFS) was significantly worse in the subgroups of high SUVmax1 and high ΔSUVmax% (median 7.0 months) than in the other subgroups (p < 0.0001). The multivariate Cox analysis of RFS identified high SUVmax1 and high ΔSUVmax% as independent prognostic factors (p = 0.0060). DTP FDG PET/CT may effectively predict relapse in patients with pancreatic cancer. The combination of SUVmax1 and ΔSUVmax% identified early recurrent patient groups more precisely than SUVmax1 alone.
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Affiliation(s)
- Takahiro Einama
- Department of Surgery, National Defense Medical College, Saitama 359-8513, Japan; (T.E.); (Y.Y.); (Y.T.); (F.K.); (K.K.); (N.Y.); (I.F.); (T.T.); (K.K.); (A.N.); (T.I.); (E.S.); (H.U.)
| | - Yoji Yamagishi
- Department of Surgery, National Defense Medical College, Saitama 359-8513, Japan; (T.E.); (Y.Y.); (Y.T.); (F.K.); (K.K.); (N.Y.); (I.F.); (T.T.); (K.K.); (A.N.); (T.I.); (E.S.); (H.U.)
| | - Yasuhiro Takihata
- Department of Surgery, National Defense Medical College, Saitama 359-8513, Japan; (T.E.); (Y.Y.); (Y.T.); (F.K.); (K.K.); (N.Y.); (I.F.); (T.T.); (K.K.); (A.N.); (T.I.); (E.S.); (H.U.)
| | - Fukumi Konno
- Department of Surgery, National Defense Medical College, Saitama 359-8513, Japan; (T.E.); (Y.Y.); (Y.T.); (F.K.); (K.K.); (N.Y.); (I.F.); (T.T.); (K.K.); (A.N.); (T.I.); (E.S.); (H.U.)
| | - Kazuki Kobayashi
- Department of Surgery, National Defense Medical College, Saitama 359-8513, Japan; (T.E.); (Y.Y.); (Y.T.); (F.K.); (K.K.); (N.Y.); (I.F.); (T.T.); (K.K.); (A.N.); (T.I.); (E.S.); (H.U.)
| | - Naoto Yonamine
- Department of Surgery, National Defense Medical College, Saitama 359-8513, Japan; (T.E.); (Y.Y.); (Y.T.); (F.K.); (K.K.); (N.Y.); (I.F.); (T.T.); (K.K.); (A.N.); (T.I.); (E.S.); (H.U.)
| | - Ibuki Fujinuma
- Department of Surgery, National Defense Medical College, Saitama 359-8513, Japan; (T.E.); (Y.Y.); (Y.T.); (F.K.); (K.K.); (N.Y.); (I.F.); (T.T.); (K.K.); (A.N.); (T.I.); (E.S.); (H.U.)
| | - Takazumi Tsunenari
- Department of Surgery, National Defense Medical College, Saitama 359-8513, Japan; (T.E.); (Y.Y.); (Y.T.); (F.K.); (K.K.); (N.Y.); (I.F.); (T.T.); (K.K.); (A.N.); (T.I.); (E.S.); (H.U.)
| | - Keita Kouzu
- Department of Surgery, National Defense Medical College, Saitama 359-8513, Japan; (T.E.); (Y.Y.); (Y.T.); (F.K.); (K.K.); (N.Y.); (I.F.); (T.T.); (K.K.); (A.N.); (T.I.); (E.S.); (H.U.)
| | - Akiko Nakazawa
- Department of Surgery, National Defense Medical College, Saitama 359-8513, Japan; (T.E.); (Y.Y.); (Y.T.); (F.K.); (K.K.); (N.Y.); (I.F.); (T.T.); (K.K.); (A.N.); (T.I.); (E.S.); (H.U.)
| | - Toshimitsu Iwasaki
- Department of Surgery, National Defense Medical College, Saitama 359-8513, Japan; (T.E.); (Y.Y.); (Y.T.); (F.K.); (K.K.); (N.Y.); (I.F.); (T.T.); (K.K.); (A.N.); (T.I.); (E.S.); (H.U.)
| | - Eiji Shinto
- Department of Surgery, National Defense Medical College, Saitama 359-8513, Japan; (T.E.); (Y.Y.); (Y.T.); (F.K.); (K.K.); (N.Y.); (I.F.); (T.T.); (K.K.); (A.N.); (T.I.); (E.S.); (H.U.)
| | - Jiro Ishida
- Tokorozawa PET Diagnostic Imaging Clinic, Saitama 359-1124, Japan;
| | - Hideki Ueno
- Department of Surgery, National Defense Medical College, Saitama 359-8513, Japan; (T.E.); (Y.Y.); (Y.T.); (F.K.); (K.K.); (N.Y.); (I.F.); (T.T.); (K.K.); (A.N.); (T.I.); (E.S.); (H.U.)
| | - Yoji Kishi
- Department of Surgery, National Defense Medical College, Saitama 359-8513, Japan; (T.E.); (Y.Y.); (Y.T.); (F.K.); (K.K.); (N.Y.); (I.F.); (T.T.); (K.K.); (A.N.); (T.I.); (E.S.); (H.U.)
- Correspondence: ; Tel.: +81-4-2995-1211
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29
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de Jong EJM, Janssen QP, Simons TFA, Besselink MG, Bonsing BA, Bouwense SAW, Geurts SME, Homs MYV, de Meijer VE, Tjan‐Heijnen VCG, van Laarhoven HWM, Valkenburg‐van Iersel LBJ, Wilmink JW, van der Geest LG, Koerkamp BG, de Vos‐Geelen J. Real-world evidence of adjuvant gemcitabine plus capecitabine vs gemcitabine monotherapy for pancreatic ductal adenocarcinoma. Int J Cancer 2022; 150:1654-1663. [PMID: 34935139 PMCID: PMC9303436 DOI: 10.1002/ijc.33916] [Citation(s) in RCA: 1] [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: 08/30/2021] [Revised: 11/12/2021] [Accepted: 12/02/2021] [Indexed: 12/30/2022]
Abstract
The added value of capecitabine to adjuvant gemcitabine monotherapy (GEM) in pancreatic ductal adenocarcinoma (PDAC) was shown by the ESPAC-4 trial. Real-world data on the effectiveness of gemcitabine plus capecitabine (GEMCAP), in patients ineligible for mFOLFIRINOX, are lacking. Our study assessed whether adjuvant GEMCAP is superior to GEM in a nationwide cohort. Patients treated with adjuvant GEMCAP or GEM after resection of PDAC without preoperative treatment were identified from The Netherlands Cancer Registry (2015-2019). The primary outcome was overall survival (OS), measured from start of chemotherapy. The treatment effect of GEMCAP vs GEM was adjusted for sex, age, performance status, tumor size, lymph node involvement, resection margin and tumor differentiation in a multivariable Cox regression analysis. Secondary outcome was the percentage of patients who completed the planned six adjuvant treatment cycles. Overall, 778 patients were included, of whom 21.1% received GEMCAP and 78.9% received GEM. The median OS was 31.4 months (95% CI 26.8-40.7) for GEMCAP and 22.1 months (95% CI 20.6-25.0) for GEM (HR: 0.71, 95% CI 0.56-0.90; logrank P = .004). After adjustment for prognostic factors, survival remained superior for patients treated with GEMCAP (HR: 0.73, 95% CI 0.57-0.92, logrank P = .009). Survival with GEMCAP was superior to GEM in most subgroups of prognostic factors. Adjuvant chemotherapy was completed in 69.5% of the patients treated with GEMCAP and 62.7% with GEM (P = .11). In this nationwide cohort of patients with PDAC, adjuvant GEMCAP was associated with superior survival as compared to GEM monotherapy and number of cycles was similar.
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Affiliation(s)
- Evelien J. M. de Jong
- Department of Internal Medicine, Division of Medical Oncology, GROW ‐ School for Oncology and Developmental BiologyMaastricht University Medical Center+MaastrichtThe Netherlands
| | | | - Tessa F. A. Simons
- Department of Internal Medicine, Division of Medical Oncology, GROW ‐ School for Oncology and Developmental BiologyMaastricht University Medical Center+MaastrichtThe Netherlands
| | - Marc G. Besselink
- Department of Surgery, Amsterdam UMCUniversity of Amsterdam, Cancer Center AmsterdamAmsterdamThe Netherlands
| | - Bert A. Bonsing
- Department of SurgeryLeiden University Medical CenterLeidenThe Netherlands
| | | | - Sandra M. E. Geurts
- Department of Internal Medicine, Division of Medical Oncology, GROW ‐ School for Oncology and Developmental BiologyMaastricht University Medical Center+MaastrichtThe Netherlands
| | | | - Vincent E. de Meijer
- Department of SurgeryUniversity of Groningen and University Medical Center GroningenGroningenThe Netherlands
| | - Vivianne C. G. Tjan‐Heijnen
- Department of Internal Medicine, Division of Medical Oncology, GROW ‐ School for Oncology and Developmental BiologyMaastricht University Medical Center+MaastrichtThe Netherlands
| | - Hanneke W. M. van Laarhoven
- Department of Medical Oncology, Amsterdam UMC, University of AmsterdamCancer Center AmsterdamAmsterdamThe Netherlands
| | - Liselot B. J. Valkenburg‐van Iersel
- Department of Internal Medicine, Division of Medical Oncology, GROW ‐ School for Oncology and Developmental BiologyMaastricht University Medical Center+MaastrichtThe Netherlands
| | - Johanna W. Wilmink
- Department of Medical Oncology, Amsterdam UMC, University of AmsterdamCancer Center AmsterdamAmsterdamThe Netherlands
| | - Lydia G. van der Geest
- Department of ResearchNetherlands Comprehensive Cancer Organization (IKNL)UtrechtThe Netherlands
| | - Bas Groot Koerkamp
- Department of SurgeryErasmus MC Cancer InstituteRotterdamThe Netherlands
| | - Judith de Vos‐Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW ‐ School for Oncology and Developmental BiologyMaastricht University Medical Center+MaastrichtThe Netherlands
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30
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Fong ZV, Qadan M. Deciphering the Etiology of Weight Loss Following Pancreatectomy. Ann Surg Oncol 2022; 29:3369-3370. [PMID: 35119548 DOI: 10.1245/s10434-022-11368-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 01/16/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.
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Pecorelli N, Licinio AW, Guarneri G, Aleotti F, Crippa S, Reni M, Falconi M, Balzano G. Prognosis of Upfront Surgery for Pancreatic Cancer: A Systematic Review and Meta-Analysis of Prospective Studies. Front Oncol 2022; 11:812102. [PMID: 35083158 PMCID: PMC8784375 DOI: 10.3389/fonc.2021.812102] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 12/13/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The rate of patients with pancreatic ductal adenocarcinoma (PDAC) receiving neoadjuvant chemotherapy is increasing, but upfront resection is still offered to most patients with resectable or borderline resectable disease. Encouraging data reported in adjuvant chemotherapy trials prompts surgeons towards upfront surgery, but such trials are subject to a significant selection bias. This systematic review aims to summarize available high-quality evidence regarding survival of patients treated with upfront surgery for PDAC. METHODS Pubmed, Cochrane, and Web of Science Databases were interrogated for prospective studies published between 2000 and 2021 that included at least a cohort of patients treated with upfront surgery for resectable or borderline resectable PDAC. The Cochrane Collaboration's risk-of-bias tool for randomized trials (RoB-2) was used to assess risk of bias in all randomized studies. Patient weighted median overall survival (OS) and disease-free survival (DFS) were calculated. RESULTS Overall, 8,341 abstracts were screened, 17 reports were reviewed in full text, and finally 5 articles and 1 conference abstract underwent data extraction. Included studies were published between 2014 and 2021. All studies were RCTs comparing different neoadjuvant treatment strategies to upfront surgery. Three studies included only resectable PDAC patients, two studies recruited patients with resectable and borderline resectable disease, and one study selected only borderline resectable patients. A total of 439 patients were included in the upfront resection cohorts of the 6 studies, ranging between 20 to 180 patients per study. The weighted median OS after upfront surgery was 18.8 (95% CI 12.4 - 20.6) months. Median DFS was 9 (95% CI 1.6 - 12.5) months. Resection rate was 74.5% (range 65-90%). Adjuvant treatment was initiated in 68% (range 43-77%) of resected patients. CONCLUSIONS High-quality data for PDAC patients undergoing upfront surgery is scarce. Meta-analysis from the included studies showed a significantly shorter OS and DFS compared to recently published studies focusing on adjuvant combination chemotherapy, suggesting that the latter may overestimate survival due to the exclusion of most patients scheduled for upfront surgery.
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Affiliation(s)
- Nicolò Pecorelli
- Faculty of Medicine, Vita-Salute San Raffaele University, Milan, Italy.,Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Alice W Licinio
- Faculty of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Guarneri
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Francesca Aleotti
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Crippa
- Faculty of Medicine, Vita-Salute San Raffaele University, Milan, Italy.,Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Michele Reni
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Falconi
- Faculty of Medicine, Vita-Salute San Raffaele University, Milan, Italy.,Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Gianpaolo Balzano
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
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Grimbergen G, Eijkelenkamp H, Heerkens HD, Raaymakers BW, Intven MPW, Meijer GJ. Intrafraction pancreatic tumor motion patterns during ungated magnetic resonance guided radiotherapy with an abdominal corset. Phys Imaging Radiat Oncol 2022; 21:1-5. [PMID: 35005257 PMCID: PMC8715205 DOI: 10.1016/j.phro.2021.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 12/07/2021] [Accepted: 12/10/2021] [Indexed: 12/25/2022] Open
Abstract
Background Stereotactic body radiotherapy (SBRT) has been shown to be a promising therapy for unresectable pancreatic tumors. However, intrafraction motion, caused by respiratory motion and organ drift, is one of the main concerns for efficient dose delivery in ungated upper abdominal radiotherapy. The aim of this study was to analyze the intrafraction gross tumor volume (GTV) motion in a clinical cohort. Materials and methods We included 13 patients that underwent online adaptive magnetic resonance (MR)-guided SBRT for malignancies in the pancreatic region (5 × 8 Gy). An abdominal corset was fitted in order to reduce the abdominal respiratory motion. Coronal and sagittal cine magnetic resonance images of the tumor region were made at 2 Hz during the entire beam-on time of each fraction. We used deformable image registration to obtain GTV motion profiles in all three directions, which were subsequently high-pass and low-pass filtered to isolate the motion caused by respiratory motion and baseline drift, respectively. Results The mean (SD) respiratory amplitudes were 4.2 (1.9) mm cranio-caudal (CC), 2.3 (1.1) mm ventral-dorsal (AP) and 1.4 (0.6) mm left–right (LR), with low variability within patients. The mean (SD) maximum baseline drifts were 1.2 (1.1) mm CC, 0.5 (0.4) mm AP and 0.5 (0.3) mm LR. The mean (SD) minimum baseline drifts were −0.7 (0.5) mm CC, −0.6 (0.5) mm AP and −0.5 (0.4) mm LR. Conclusion Overall tumor motion during treatment was small and interfractionally stable. These findings show that high-precision ungated MR-guided SBRT is feasible with an abdominal corset.
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Affiliation(s)
- Guus Grimbergen
- Department of Radiation Oncology, University Medical Center Utrecht, the Netherlands
| | - Hidde Eijkelenkamp
- Department of Radiation Oncology, University Medical Center Utrecht, the Netherlands
| | - Hanne D Heerkens
- Department of Radiation Oncology, University Medical Center Utrecht, the Netherlands
| | - Bas W Raaymakers
- Department of Radiation Oncology, University Medical Center Utrecht, the Netherlands
| | - Martijn P W Intven
- Department of Radiation Oncology, University Medical Center Utrecht, the Netherlands
| | - Gert J Meijer
- Department of Radiation Oncology, University Medical Center Utrecht, the Netherlands
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Halle-Smith JM, Hall L, Daamen LA, Hodson J, Pande R, Young A, Jamieson NB, Lamarca A, van Santvoort HC, Molenaar IQ, Valle JW, Roberts KJ. Clinical benefit of surveillance after resection of pancreatic ductal adenocarcinoma: A systematic review and meta-analysis. Eur J Surg Oncol 2021; 47:2248-2255. [PMID: 34034941 DOI: 10.1016/j.ejso.2021.04.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 04/03/2021] [Accepted: 04/26/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The value of routine surveillance after resection of pancreatic ductal adenocarcinoma (PDAC) is unclear, and expert guidelines offer conflicting recommendations. This study is a systematic review of evidence for surveillance programs. METHODS A systematic review of studies evaluating different surveillance methods was undertaken. A meta-analysis was performed for those studies reporting rates of asymptomatic recurrence, treatment of recurrence and overall survival, according to different surveillance methods. RESULTS Ten studies were included in the literature review, with five studies appropriate for meta-analysis (1596 patients). Patients within active surveillance programs were more likely to have recurrence detected at an asymptomatic stage (Pooled Rate: 49.3% vs. 19.1%, p = 0.043). Within studies reporting these outcomes, patients with asymptomatic recurrence were more likely to receive treatment for recurrence (Odds Ratio 3.49; 95% CI: 1.73-7.07; p < 0.001) and had longer overall survival (Mean Difference: 9.5 months; 95% CI: 4.1-14.8; p < 0.001) than those with symptoms at time of recurrence. DISCUSSION Routine surveillance after surgery for PDAC appears to detect more patients at an asymptomatic stage. Data from these non-randomised trials also suggest that treatment rates and survival may be superior in patients were recurrence is detected when asymptomatic. As such, these data suggest that routine surveillance may improve patient outcomes, although an appropriately conducted trial would be required to address concerns that various sources of bias may be affecting these results.
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Affiliation(s)
- James M Halle-Smith
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Lewis Hall
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom; College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Lois A Daamen
- Department of Surgery, UMC Utrecht Cancer Center, Utrecht University, Utrecht, the Netherlands
| | - James Hodson
- Medical Statistics, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Rupaly Pande
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Alastair Young
- Department of Pancreaticobiliary Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Nigel B Jamieson
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom; West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - Angela Lamarca
- Medical Oncology Department, The Christie NHS Foundation Trust / University of Manchester, Manchester, UK; Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht University, the Netherlands
| | - Izaak Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht University, the Netherlands
| | - Juan W Valle
- Medical Oncology Department, The Christie NHS Foundation Trust / University of Manchester, Manchester, UK; Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Keith J Roberts
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom; College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.
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Wong SK, Gondara L, Renouf DJ, Lim HJ, Loree JM, Davies JM, Gill S. Impact of surveillance among patients with resected pancreatic cancer following adjuvant chemotherapy. J Gastrointest Oncol 2021; 12:446-454. [PMID: 34012638 DOI: 10.21037/jgo-20-422] [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] [Indexed: 11/06/2022] Open
Abstract
Background Pancreatic adenocarcinoma carries a high risk of recurrence even after surgery and adjuvant chemotherapy. Current guidelines do not endorse routine surveillance imaging due to lack of evidence supporting a survival benefit. With current first-line palliative chemotherapy options, it is unclear whether surveillance allows for early detection of asymptomatic disease and therefore an improved opportunity to offer chemotherapy to fit patients. We sought to describe patterns of surveillance of resected pancreatic cancer at British Columbia (BC) Cancer and determine whether utilization of computerized tomography (CT) scans affected likelihood of receiving palliative chemotherapy at the time of recurrence. Methods A retrospective review was completed to identify patients treated at BC Cancer centres between 2010-2016 who had undergone curative intent resection and received at least one cycle of adjuvant chemotherapy. Information was collected on baseline characteristics, imaging scans done between adjuvant chemotherapy and recurrence, and receipt of palliative chemotherapy. Two cohorts were defined based on number of scans done between completion of adjuvant chemotherapy and recurrence: those with only 1 scan were defined as "symptomatic" recurrences and patients who had undergone more than 1 scan were considered "surveillance" recurrences. Results In total, 142 patients were included of which 115 (81%) patients developed recurrence. There were 22 patients (19%) in the "symptomatic" cohort and 93 patients (81%) in the "surveillance" cohort. Median time to recurrence 274 days (9.1 months) in the symptomatic cohort compared to 471 days (15.7 months) in the surveillance group. Patients who underwent surveillance scans were more likely to receive palliative chemotherapy at the time of recurrence, though statistical significance was not reached: 51% in surveillance group versus 27% in symptomatic group [odds ratio (OR) 2.11, 95% confidence interval (CI): 0.75-6.58, P=0.17]. Conclusions Despite the absence of surveillance recommendations, the majority of patients underwent surveillance imaging. We demonstrated a non-significant increase in the likelihood of receiving palliative chemotherapy among patients who underwent surveillance scans. With more efficacious palliative chemotherapy options available, studies to determine whether receipt of chemotherapy in asymptomatic recurrences translates into improved survival and/or quality of life are warranted.
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Luu AM, Belyaev O, Höhn P, Praktiknjo M, Janot M, Uhl W, Braumann C. Late recurrences of pancreatic cancer in patients with long-term survival after pancreaticoduodenectomy. J Gastrointest Oncol 2021; 12:474-483. [PMID: 34012641 PMCID: PMC8107632 DOI: 10.21037/jgo-20-433] [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: 10/09/2020] [Accepted: 01/17/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Pancreatic cancer remains a relevant clinical problem due to poor prognosis. Even after curative pancreaticoduodenectomy tumor recurrences occur in up to 80%. Risk factors for postoperative tumor recurrences have been identified before, but data on risk factors for tumor recurrences in patients with long-term-survival is scarce. METHODS In this retrospective study consecutive long-term survival-patients (defined as at least 60 months survival) undergoing pancreaticoduodenectomy for pancreatic cancer from 2007-2014 were identified in the 2nd largest pancreatic surgery center in Germany. Clinical, pathohistological and laboratory values were analyzed to identify risk factors for tumor recurrence. RESULTS Thirty-four of one-hundred-sixty-seven patients were identified as long-term-survival-patients in the study period. Of those, 10 patients (29.4%) suffered from tumor recurrence. Lymph vessel invasion was identified as an independent risk factor (P=0.031, hazard ratio 13.127, 95% confidence interval: 1.270-135.698). Median postoperative time to tumor recurrence in long-term-survival-patients was 49 months. Overall survival after diagnosis of tumor recurrence was 33 months. 80% (N=8) of the patients were asymptomatic. Half of the patients (N=5) suffered from local disease, with 40% undergoing curative tumor resection. CA 19-9 levels were significantly elevated at 57 U/mL (normal <27 U/mL). CONCLUSIONS Tumor recurrence in long-term-survival-patients is typically asymptomatic. Especially long-term-survival-patients with lymph vessel invasion are more likely to develop tumor recurrence. Therefore, a structured follow-up program including CT-scans and CA 19-9 surveillance must be continued in all patients undergoing pancreaticoduodenectomy even in cases of long-term-survival.
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Affiliation(s)
- Andreas Minh Luu
- Department of General and Visceral Surgery, St. Josef-Hospital, Ruhr - University Bochum, Gudrunstr. 56, 44791 Bochum, Germany
| | - Orlin Belyaev
- Department of General and Visceral Surgery, St. Josef-Hospital, Ruhr - University Bochum, Gudrunstr. 56, 44791 Bochum, Germany
| | - Philipp Höhn
- Department of General and Visceral Surgery, St. Josef-Hospital, Ruhr - University Bochum, Gudrunstr. 56, 44791 Bochum, Germany
| | | | - Monika Janot
- Department of General and Visceral Surgery, St. Josef-Hospital, Ruhr - University Bochum, Gudrunstr. 56, 44791 Bochum, Germany
| | - Waldemar Uhl
- Department of General and Visceral Surgery, St. Josef-Hospital, Ruhr - University Bochum, Gudrunstr. 56, 44791 Bochum, Germany
| | - Chris Braumann
- Department of General and Visceral Surgery, St. Josef-Hospital, Ruhr - University Bochum, Gudrunstr. 56, 44791 Bochum, Germany
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Real-world patterns of adjuvant chemotherapy treatment for patients with resected pancreatic adenocarcinoma. Med Oncol 2021; 38:18. [PMID: 33534008 DOI: 10.1007/s12032-021-01469-y] [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: 12/11/2020] [Accepted: 01/22/2021] [Indexed: 12/16/2022]
Abstract
The aim of the study was to analyze the real-world treatment patterns of adjuvant chemotherapy administration among patients with resected pancreatic adenocarcinoma. Cases with non-metastatic pancreatic adenocarcinoma, diagnosed 2007-2018, treated with upfront surgical resection, and recorded within Alberta Cancer registry were accessed. Multivariable logistic regression analysis was conducted to evaluate factors predicting use of adjuvant chemotherapy. Kaplan-Meier survival estimates and multivariable Cox regression analysis were used to compare overall survival among patients treated with adjuvant gemcitabine versus those treated with adjuvant gemcitabine + capecitabine. A total of 695 patients who have undergone upfront surgical treatment of pancreatic adenocarcinoma, including 445 patients (64%) who received adjuvant chemotherapy and 250 patients (36%) who did not receive adjuvant chemotherapy. The following factors were associated with lower probability to receive adjuvant chemotherapy: older age (OR 0.94; 95% CI 0.93-0.96), node negativity (OR 0.47; 95% CI 0.33-0.67), higher Charlson comorbidity index (OR 0.86; 95% CI 0.74-0.99), and living within the Northern zone of the province (OR for Calgary zone versus North zone: 2.24; 95% CI 1.29-3.90). Within patients who received adjuvant gemcitabine ± capecitabine, factors associated with worse overall survival included higher Charlson comorbidity index (HR 1.18; 95% CI 1.00-1.40), and node-positive disease (HR for node-negative versus node-positive disease: 0.51; 95% CI 0.33-0.78). Type of chemotherapy was not predictive of overall survival (HR for gemcitabine versus gemcitabine plus capecitabine: 1.40; 95% CI 0.98-2.00). P value for interaction between type of chemotherapy and nodal status was 0.038. In this real-world study, the added benefit of adjuvant gemcitabine + capecitabine (compared to adjuvant gemcitabine) seems to be limited to patients with node-positive disease.
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