1
|
AlMasri SS, Zenati MS, Desilva A, Nassour I, Boone BA, Singhi AD, Bartlett DL, Liotta LA, Espina V, Loughran P, Lotze MT, Paniccia A, Zeh HJ, Zureikat AH, Bahary N. Encouraging long-term survival following autophagy inhibition using neoadjuvant hydroxychloroquine and gemcitabine for high-risk patients with resectable pancreatic carcinoma. Cancer Med 2021; 10:7233-7241. [PMID: 34559451 PMCID: PMC8525088 DOI: 10.1002/cam4.4211] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 07/09/2021] [Accepted: 08/03/2021] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Preoperative autophagy inhibition with hydroxychloroquine (HCQ) in combination with gemcitabine in pancreatic adenocarcinoma (PDAC) has been shown to be safe and effective in inducing a serum biomarker response and increase resection rates in a previous phase I/II clinical trial. We aimed to analyze the long-term outcomes of preoperative HCQ with gemcitabine for this cohort. METHODS A review of patients enrolled between July 2010 and February 2013 in the completed phase I/II single arm (two doses of fixed-dose gemcitabine (1500 mg/m2 ) in combination with oral hydroxychloroquine administered for 31 consecutive days until the day of surgery for high-risk pancreatic cancer) was undertaken. Progression-free survival (PFS) and overall survival analysis (OS) using Kaplan-Meier estimates were performed. RESULTS Of 35 patients initially enrolled, 29 patients underwent surgical resection (median age at diagnosis: 62 years, 45% females). Median duration of follow-up was 7.5 years. There was a median 15% decrease in the serum CA19-9 levels following completion of neoadjuvant therapy and 83% of the cohort underwent a pancreaticoduodenectomy, 7 (24%) patients had a concomitant venous resection. On histopathology, 14 (48%) patients had at least a partial treatment response. The median PFS and OS were 11 months (95% Confidence interval [CI]: 7-28) and 31 months (95% CI: 13-47), respectively, while 9 (31%) patients survived beyond 5 years from diagnosis; a rate that compares very favorably with contemporaneous series. CONCLUSION Compared to historical data, neoadjuvant autophagy inhibition with HCQ plus gemcitabine is associated with encouraging long-term survival for patients with PDAC.
Collapse
Affiliation(s)
| | - Mazen S. Zenati
- Department of Surgery, Epidemiology, Clinical and Translational ScienceUniversity of PittsburghPittsburghPAUSA
| | - Annissa Desilva
- Department of SurgeryUniversity of PittsburghPittsburghPAUSA
| | - Ibrahim Nassour
- Department of SurgeryUniversity of PittsburghPittsburghPAUSA
| | - Brian A. Boone
- Department of SurgeryWest Virginia UniversityMorgantownWVUSA
| | - Aatur D. Singhi
- Department of PathologyUniversity of PittsburghPittsburghPAUSA
| | | | - Lance A. Liotta
- Center for Applied Proteomics and Molecular MedicineGeorge Mason UniversityManassasVAUSA
| | - Virginia Espina
- Center for Applied Proteomics and Molecular MedicineGeorge Mason UniversityManassasVAUSA
| | | | - Michael T. Lotze
- Department of SurgeryUniversity of PittsburghPittsburghPAUSA
- Department of ImmunologyUniversity of PittsburghPittsburghPAUSA
- Department of BioengineeringUniversity of PittsburghPittsburghPAUSA
| | | | - Herbert J. Zeh
- Department of SurgeryUniversity of Texas SouthwesternDallasTXUSA
| | | | - Nathan Bahary
- Department of Internal MedicineUniversity of PittsburghPAUSA
| |
Collapse
|
2
|
De Lellis L, Veschi S, Tinari N, Mokini Z, Carradori S, Brocco D, Florio R, Grassadonia A, Cama A. Drug Repurposing, an Attractive Strategy in Pancreatic Cancer Treatment: Preclinical and Clinical Updates. Cancers (Basel) 2021; 13:3946. [PMID: 34439102 PMCID: PMC8394389 DOI: 10.3390/cancers13163946] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/26/2021] [Accepted: 08/02/2021] [Indexed: 12/11/2022] Open
Abstract
Pancreatic cancer (PC) is one of the deadliest malignancies worldwide, since patients rarely display symptoms until an advanced and unresectable stage of the disease. Current chemotherapy options are unsatisfactory and there is an urgent need for more effective and less toxic drugs to improve the dismal PC therapy. Repurposing of non-oncology drugs in PC treatment represents a very promising therapeutic option and different compounds are currently being considered as candidates for repurposing in the treatment of this tumor. In this review, we provide an update on some of the most promising FDA-approved, non-oncology, repurposed drug candidates that show prominent clinical and preclinical data in pancreatic cancer. We also focus on proposed mechanisms of action and known molecular targets that they modulate in PC. Furthermore, we provide an explorative bioinformatic analysis, which suggests that some of the PC repurposed drug candidates have additional, unexplored, oncology-relevant targets. Finally, we discuss recent developments regarding the immunomodulatory role displayed by some of these drugs, which may expand their potential application in synergy with approved anticancer immunomodulatory agents that are mostly ineffective as single agents in PC.
Collapse
Affiliation(s)
- Laura De Lellis
- Department of Pharmacy, G. d’Annunzio University of Chieti-Pescara, 66100 Chieti, Italy; (S.V.); (S.C.); (D.B.); (R.F.)
| | - Serena Veschi
- Department of Pharmacy, G. d’Annunzio University of Chieti-Pescara, 66100 Chieti, Italy; (S.V.); (S.C.); (D.B.); (R.F.)
| | - Nicola Tinari
- Department of Medical, Oral and Biotechnological Sciences, G. d’Annunzio University of Chieti-Pescara, 66100 Chieti, Italy; (N.T.); (A.G.)
- Center for Advanced Studies and Technology—CAST, G. d’Annunzio University of Chieti-Pescara, 66100 Chieti, Italy
| | - Zhirajr Mokini
- European Society of Anaesthesiology and Intensive Care (ESAIC) Mentorship Programme, ESAIC, 24 Rue des Comédiens, BE-1000 Brussels, Belgium;
| | - Simone Carradori
- Department of Pharmacy, G. d’Annunzio University of Chieti-Pescara, 66100 Chieti, Italy; (S.V.); (S.C.); (D.B.); (R.F.)
| | - Davide Brocco
- Department of Pharmacy, G. d’Annunzio University of Chieti-Pescara, 66100 Chieti, Italy; (S.V.); (S.C.); (D.B.); (R.F.)
| | - Rosalba Florio
- Department of Pharmacy, G. d’Annunzio University of Chieti-Pescara, 66100 Chieti, Italy; (S.V.); (S.C.); (D.B.); (R.F.)
| | - Antonino Grassadonia
- Department of Medical, Oral and Biotechnological Sciences, G. d’Annunzio University of Chieti-Pescara, 66100 Chieti, Italy; (N.T.); (A.G.)
- Center for Advanced Studies and Technology—CAST, G. d’Annunzio University of Chieti-Pescara, 66100 Chieti, Italy
| | - Alessandro Cama
- Department of Pharmacy, G. d’Annunzio University of Chieti-Pescara, 66100 Chieti, Italy; (S.V.); (S.C.); (D.B.); (R.F.)
- Center for Advanced Studies and Technology—CAST, G. d’Annunzio University of Chieti-Pescara, 66100 Chieti, Italy
| |
Collapse
|
3
|
Liu H, Zenati MS, Rieser CJ, Al-Abbas A, Lee KK, Singhi AD, Bahary N, Hogg ME, Zeh HJ, Zureikat AH. CA19-9 Change During Neoadjuvant Therapy May Guide the Need for Additional Adjuvant Therapy Following Resected Pancreatic Cancer. Ann Surg Oncol 2020; 27:3950-3960. [PMID: 32318949 PMCID: PMC7931260 DOI: 10.1245/s10434-020-08468-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Neoadjuvant therapy (NAT) is increasingly utilized for pancreatic cancer, however the added benefit of adjuvant therapy (AT) in this setting is unknown. We hypothesized that the magnitude of CA19-9 response to NAT can guide the need for further AT in resected pancreatic cancer. METHODS CA19-9 secretors who received NAT for pancreatic cancer during 2008-2016 at a single institution were analyzed and CA19-9 response (difference between pre- and post-NAT values) was measured. Kaplan-Meier estimators and Cox proportional hazard ratio models were used to determine the optimal CA19-9 response at which AT ceases to confer any additional survival benefit after NAT. RESULTS A total of 241 patients (mean age 65.4 years, 50% female) with complete CA19-9 data who underwent NAT followed by resection were analyzed. In a cohort of patients (n = 78) in whom CA19-9 normalized with a decrease > 50% after NAT (optimal responders), AT was not associated with additional survival benefit (40.6 vs. 39.0 months, p = 0.815). Conversely, in the cohort of patients (n = 163) in whom NAT was not associated with normalization and a decrease of ≤ 50% in CA19-9 (suboptimal responders), receipt of AT was associated with a survival benefit (34.5 vs. 19.1 months, p < 0.001) following NAT. A Cox proportional hazards model confirmed CA19-9 normalization and decrease > 50% during NAT to predict no additional survival benefit from AT. CONCLUSIONS The magnitude of CA19-9 response to NAT may predict the need for further AT in resected pancreatic cancer. Prospective studies are needed to elucidate the optimal interplay of NAT and AT in pancreatic cancer.
Collapse
Affiliation(s)
- Hao Liu
- Division of Gastrointestinal Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mazen S Zenati
- Department of Surgery and Epidemiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Caroline J Rieser
- Division of Gastrointestinal Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Amr Al-Abbas
- Division of Gastrointestinal Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kenneth K Lee
- Division of Gastrointestinal Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Aatur D Singhi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Nathan Bahary
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Melissa E Hogg
- Department of Surgery, NorthShore University Health System, Chicago, IL, USA
| | - Herbert J Zeh
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Amer H Zureikat
- Division of Gastrointestinal Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| |
Collapse
|
4
|
Paniccia A, Gleisner AL, Zenati MS, Al Abbas AI, Jung JP, Bahary N, Lee KKW, Bartlett D, Hogg ME, Zeh HJ, Zureikat AH. Predictors of Disease Progression or Performance Status Decline in Patients Undergoing Neoadjuvant Therapy for Localized Pancreatic Head Adenocarcinoma. Ann Surg Oncol 2020; 27:2961-2971. [DOI: 10.1245/s10434-020-08257-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Indexed: 12/20/2022]
|
5
|
Zeh HJ, Bahary N, Boone BA, Singhi AD, Miller-Ocuin JL, Normolle DP, Zureikat AH, Hogg ME, Bartlett DL, Lee KK, Tsung A, Marsh JW, Murthy P, Tang D, Seiser N, Amaravadi RK, Espina V, Liotta L, Lotze MT. A Randomized Phase II Preoperative Study of Autophagy Inhibition with High-Dose Hydroxychloroquine and Gemcitabine/Nab-Paclitaxel in Pancreatic Cancer Patients. Clin Cancer Res 2020; 26:3126-3134. [PMID: 32156749 DOI: 10.1158/1078-0432.ccr-19-4042] [Citation(s) in RCA: 127] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 02/05/2020] [Accepted: 03/06/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE We hypothesized that autophagy inhibition would increase response to chemotherapy in the preoperative setting for patients with pancreatic adenocarcinoma. We performed a randomized controlled trial to assess the autophagy inhibitor hydroxychloroquine in combination with gemcitabine and nab-paclitaxel. PATIENTS AND METHODS Participants with potentially resectable tumors were randomized to two cycles of nab-paclitaxel and gemcitabine (PG) alone or with hydroxychloroquine (PGH), followed by resection. The primary endpoint was histopathologic response in the resected specimen. Secondary clinical endpoints included serum CA 19-9 biomarker response and margin negative R0 resection. Exploratory endpoints included markers of autophagy, immune infiltrate, and serum cytokines. RESULTS Thirty-four patients in the PGH arm and 30 in the PG arm were evaluable for the primary endpoint. The PGH arm demonstrated statistically improved Evans grade histopathologic responses (P = 0.00016), compared with control. In patients with elevated CA 19-9, a return to normal was associated with improved overall and recurrence-free survival (P < 0.0001). There were no differences in serious adverse events between arms and chemotherapy dose number was equivalent. The PGH arm had greater evidence of autophagy inhibition in their resected specimens (increased SQSTM1, P = 0.027, as well as increased immune cell tumor infiltration, P = 0.033). Overall survival (P = 0.59) and relapse-free survival (P = 0.55) did not differ between the two arms. CONCLUSIONS The addition of hydroxychloroquine to preoperative gemcitabine and nab-paclitaxel chemotherapy in patients with resectable pancreatic adenocarcinoma resulted in greater pathologic tumor response, improved serum biomarker response, and evidence of autophagy inhibition and immune activity.
Collapse
Affiliation(s)
- Herbert J Zeh
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nathan Bahary
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Brian A Boone
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Aatur D Singhi
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Daniel P Normolle
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Amer H Zureikat
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Melissa E Hogg
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David L Bartlett
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kenneth K Lee
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Allan Tsung
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - J Wallis Marsh
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Pranav Murthy
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Daolin Tang
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Natalie Seiser
- HPB and Transplant Institute at St. Vincent's Medical Center, Los Angeles, California
| | - Ravi K Amaravadi
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Virginia Espina
- Center for Applied Proteomics and Molecular Medicine, George Mason University, Manassas, Virginia
| | - Lance Liotta
- Center for Applied Proteomics and Molecular Medicine, George Mason University, Manassas, Virginia
| | - Michael T Lotze
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Immunology, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
6
|
Versteijne E, Vogel JA, Besselink MG, Busch ORC, Wilmink JW, Daams JG, van Eijck CHJ, Groot Koerkamp B, Rasch CRN, van Tienhoven G. Meta-analysis comparing upfront surgery with neoadjuvant treatment in patients with resectable or borderline resectable pancreatic cancer. Br J Surg 2018; 105:946-958. [PMID: 29708592 PMCID: PMC6033157 DOI: 10.1002/bjs.10870] [Citation(s) in RCA: 340] [Impact Index Per Article: 56.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 11/14/2017] [Accepted: 03/07/2018] [Indexed: 12/11/2022]
Abstract
Background Studies comparing upfront surgery with neoadjuvant treatment in pancreatic cancer may report only patients who underwent resection and so survival will be skewed. The aim of this study was to report survival by intention to treat in a comparison of upfront surgery versus neoadjuvant treatment in resectable or borderline resectable pancreatic cancer. Methods MEDLINE, Embase and the Cochrane Library were searched for studies reporting median overall survival by intention to treat in patients with resectable or borderline resectable pancreatic cancer treated with or without neoadjuvant treatment. Secondary outcomes included overall and R0 resection rate, pathological lymph node rate, reasons for unresectability and toxicity of neoadjuvant treatment. Results In total, 38 studies were included with 3484 patients, of whom 1738 (49·9 per cent) had neoadjuvant treatment. The weighted median overall survival by intention to treat was 18·8 months for neoadjuvant treatment and 14·8 months for upfront surgery; the difference was larger among patients whose tumours were resected (26·1 versus 15·0 months respectively). The overall resection rate was lower with neoadjuvant treatment than with upfront surgery (66·0 versus 81·3 per cent; P < 0·001), but the R0 rate was higher (86·8 (95 per cent c.i. 84·6 to 88·7) versus 66·9 (64·2 to 69·6) per cent; P < 0·001). Reported by intention to treat, the R0 rates were 58·0 and 54·9 per cent respectively (P = 0·088). The pathological lymph node rate was 43·8 per cent after neoadjuvant therapy and 64·8 per cent in the upfront surgery group (P < 0·001). Toxicity of at least grade III was reported in up to 64 per cent of the patients. Conclusion Neoadjuvant treatment appears to improve overall survival by intention to treat, despite lower overall resection rates for resectable or borderline resectable pancreatic cancer. PROSPERO registration number: CRD42016049374. Improved survival with neoadjuvant treatment
Collapse
Affiliation(s)
- E Versteijne
- Department of Radiation Oncology, Cancer Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - J A Vogel
- Department of Surgery, Cancer Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - M G Besselink
- Department of Surgery, Cancer Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - O R C Busch
- Department of Surgery, Cancer Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - J W Wilmink
- Department of Medical Oncology, Cancer Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - J G Daams
- Medical Library, Academic Medical Centre, Amsterdam, The Netherlands
| | - C H J van Eijck
- Department of Surgery, Erasmus Medical Centre, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - B Groot Koerkamp
- Department of Surgery, Erasmus Medical Centre, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - C R N Rasch
- Department of Radiation Oncology, Cancer Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - G van Tienhoven
- Department of Radiation Oncology, Cancer Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | | |
Collapse
|
7
|
Rahman SH, Urquhart R, Molinari M. Neoadjuvant therapy for resectable pancreatic cancer. World J Gastrointest Oncol 2017; 9:457-465. [PMID: 29290916 PMCID: PMC5740086 DOI: 10.4251/wjgo.v9.i12.457] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Revised: 08/24/2017] [Accepted: 09/16/2017] [Indexed: 02/05/2023] Open
Abstract
The use of neoadjuvant therapies has played a major role for borderline resectable and locally advanced pancreatic cancers (PCs). For this group of patients, preoperative chemotherapy or chemoradiation has increased the likelihood of surgery with negative resection margins and overall survival. On the other hand, for patients with resectable PC, the main rationale for neoadjuvant therapy is that the overall survival with current strategies is unsatisfactory. There is a consensus that we need new treatments to improve the overall survival and quality of life of patients with PC. However, without strong scientific evidence supporting the theoretical advantages of neoadjuvant therapies, these potential benefits might turn out not to be worth the risk of tumors progression while waiting for surgery. The focus of this paper is to provide the readers an overview of the most recent evidence on this subject.
Collapse
Affiliation(s)
| | - Robin Urquhart
- Department of Surgery, Dalhousie University, Halifax B3H 2Y9, Nova Scotia, Canada
| | - Michele Molinari
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, United States
| |
Collapse
|
8
|
Maggi JC, Hogg ME, Zureikat AH, Zeh HJ. Update on the Management of Pancreatic Cancer: Determinants for Surgery and Widening the Therapeutic Window of Surgical Resection. CURRENT SURGERY REPORTS 2016. [DOI: 10.1007/s40137-016-0146-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
9
|
Khorana AA, Mangu PB, Berlin J, Engebretson A, Hong TS, Maitra A, Mohile SG, Mumber M, Schulick R, Shapiro M, Urba S, Zeh HJ, Katz MHG. Potentially Curable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol 2016; 34:2541-56. [PMID: 27247221 DOI: 10.1200/jco.2016.67.5553] [Citation(s) in RCA: 260] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To provide evidence-based recommendations to oncologists and others on potentially curative therapy for patients with localized pancreatic cancer. METHODS ASCO convened a panel of medical oncology, radiation oncology, surgical oncology, palliative care, and advocacy experts and conducted a systematic review of literature from January 2002 to June 2015. Outcomes included overall survival, disease-free survival, progression-free survival, and adverse events. RESULTS Nine randomized controlled trials met the systematic review criteria. RECOMMENDATIONS A multiphase computed tomography scan of the abdomen and pelvis or magnetic resonance imaging should be performed for all patients to assess the anatomic relationships of the primary tumor and for the presence of intra-abdominal metastases. Baseline performance status, comorbidity profile, and goals of care should be evaluated and established. Primary surgical resection is recommended for all patients who have no metastases, appropriate performance and comorbidity profiles, and no radiographic interface between primary tumor and mesenteric vasculature. Preoperative therapy is recommended for patients who meet specific characteristics. All patients with resected pancreatic cancer who did not receive preoperative therapy should be offered 6 months of adjuvant chemotherapy in the absence of contraindications. Adjuvant chemoradiation may be offered to patients who did not receive preoperative therapy with microscopically positive margins (R1) after resection and/or who had node-positive disease after completion of 4 to 6 months of systemic adjuvant chemotherapy. Patients should have a full assessment of symptoms, psychological status, and social supports and should receive palliative care early. Patients who have completed treatment and have no evidence of disease should be monitored. Additional information is available at www.asco.org/guidelines/PCPC and www.asco.org/guidelineswiki.
Collapse
Affiliation(s)
- Alok A Khorana
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Pamela B Mangu
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Jordan Berlin
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Anitra Engebretson
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Theodore S Hong
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Anirban Maitra
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Supriya G Mohile
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Matthew Mumber
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Richard Schulick
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Marc Shapiro
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Susan Urba
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Herbert J Zeh
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Matthew H G Katz
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| |
Collapse
|
10
|
Boone BA, Bahary N, Zureikat AH, Moser AJ, Normolle DP, Wu WC, Singhi AD, Bao P, Bartlett DL, Liotta LA, Espina V, Loughran P, Lotze MT, Zeh HJ. Safety and Biologic Response of Pre-operative Autophagy Inhibition in Combination with Gemcitabine in Patients with Pancreatic Adenocarcinoma. Ann Surg Oncol 2015; 22:4402-10. [PMID: 25905586 PMCID: PMC4663459 DOI: 10.1245/s10434-015-4566-4] [Citation(s) in RCA: 173] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Indexed: 02/07/2023]
Abstract
PURPOSE Autophagy is a cell survival mechanism that plays a critical role in pancreatic carcinogenesis. Murine studies have previously demonstrated that treatment with the late-autophagy inhibitor chloroquine in combination with chemotherapy limited tumor growth. METHODS In this phase 1/2 trial, we examined treatment with hydroxychloroquine (HCQ) and gemcitabine for patients with pancreatic adenocarcinoma. The primary endpoints were safety and tolerability, evaluated by Storer's dose escalation design. Secondary endpoints were CA 19-9 biomarker response, R0 resection rates, survival, and correlative studies of autophagy. RESULTS Thirty-five patients were enrolled. There were no dose-limiting toxicities and no grade 4/5 events related to treatment. Nineteen patients (61 %) had a decrease in CA 19-9 after treatment. Twenty-nine patients (94 %) underwent surgical resection as scheduled, with a 77 % R0 resection rate. Median overall survival was 34.8 months (95 % confidence interval, 11.57 to not reached). Patients who had more than a 51 % increase in the autophagy marker LC3-II in circulating peripheral blood mononuclear cells had improvement in disease-free survival (15.03 vs. 6.9 months, p < 0.05) and overall survival (34.83 vs. 10.83 months, p < 0.05). No outcome differences were demonstrated in the 81 % of patients with abnormal p53 expression assessed by immunohistochemistry in the resected specimens. CONCLUSIONS Preoperative autophagy inhibition with HCQ plus gemcitabine is safe and well tolerated. Surrogate biomarker responses (CA 19-9) and surgical oncologic outcomes were encouraging. p53 status was not associated with adverse outcomes.
Collapse
Affiliation(s)
- Brian A Boone
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nathan Bahary
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Amer H Zureikat
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - A James Moser
- Institute for Hepatobiliary and Pancreatic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Daniel P Normolle
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Wen-Chi Wu
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Aatur D Singhi
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Phillip Bao
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - David L Bartlett
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lance A Liotta
- Center for Applied Proteomics and Molecular Medicine, George Mason University, Manassas, VA, USA
| | - Virginia Espina
- Center for Applied Proteomics and Molecular Medicine, George Mason University, Manassas, VA, USA
| | - Patricia Loughran
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael T Lotze
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Herbert J Zeh
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
| |
Collapse
|
11
|
Boone BA, Steve J, Zenati MS, Hogg ME, Singhi AD, Bartlett DL, Zureikat AH, Bahary N, Zeh HJ. Serum CA 19-9 response to neoadjuvant therapy is associated with outcome in pancreatic adenocarcinoma. Ann Surg Oncol 2014; 21:4351-8. [PMID: 25092157 DOI: 10.1245/s10434-014-3842-z] [Citation(s) in RCA: 125] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Baseline carbohydrate antigen 19-9 (CA 19-9) is a useful prognostic marker in pancreatic ductal adenocarcinoma (PDA); however, data on the significance of a change in CA 19-9 following neoadjuvant therapy are lacking. METHODS All patients receiving neoadjuvant therapy for PDA from July 2010 to February 2013 were retrospectively reviewed. Resection rate, R0 resection rate, need for venous resection, and overall survival were correlated to CA 19-9 response. Fisher's exact test, Kaplan-Meier survival analysis, and multivariate analysis using Cox regression were used. RESULTS A total of 78 patients were studied (21 patients with resectable disease, 40 borderline resectable, and 17 with locally advanced disease). A variety of chemotherapies ± radiation were utilized during the study period. Overall, 56 patients (72 %) had a decrease in CA 19-9 of >50 % with neoadjuvant treatment. In borderline resectable patients, CA 19-9 response of >50 % predicted R0 resection (odds ratio 4.2; p = 0.05). In borderline resectable patients who had an increase in CA 19-9, none of five (0 %) underwent R0 resection compared with 80 % of the remaining cohort (p = 0.001). The complete pathologic response rate was 29 % in patients who had a CA 19-9 response of >90 % versus 0 % in the remaining patients (p < 0.001). A CA 19-9 response of >50 % resulted in improved overall survival (28.0 vs. 11.1 months; p < 0.0001) and was an independent predictor of survival (hazard ratio 0.26; 95 % CI 0.13-0.55; p < 0.0001). CONCLUSIONS CA 19-9 response to neoadjuvant therapy is associated with R0 resection rate, histopathologic response, and survival. Incorporation of this easily obtainable biomarker into future clinical trials may facilitate more rapid evaluation of novel regimens.
Collapse
Affiliation(s)
- Brian A Boone
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Tummala P, Howard T, Agarwal B. Dramatic Survival Benefit Related to R0 Resection of Pancreatic Adenocarcinoma in Patients With Tumor ≤25 mm in Size and ≤1 Involved Lymph Nodes. Clin Transl Gastroenterol 2013; 4:e33. [PMID: 23515131 PMCID: PMC3615697 DOI: 10.1038/ctg.2013.4] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES: To evaluate i) the relative importance of R0 resection, tumor size and peripancreatic lymph node (LN) status are significant determinants of survival benefit following upfront surgery for pancreatic adenocarcinoma (PaCa), ii) whether R0 resection confers survival benefit in all patients or a patient subset with certain favorable prognostic factors. METHODS: Retrospective analysis of patients (2001–2010) who underwent planned potentially curative surgical resection without neoadjuvant therapy for PaCa. RESULTS: Among 154 patients, median survival following R0 (n=105) and R1 resections was 26.8 and 17.7 months, respectively (P=0.010). Tumor size and LN status were significant determinants of survival following R0 resection. There were no differences in survival based on tumor size and LN in patients with R1 resection. Median survival was 17.7 months following R1 resection and was 70.9 months (P<0.001) and 22.2 months (P=0.44) in patients with tumor ≤25 mm in size and ≤1 involved LN and in the remaining patients in the cohort respectively following R0 resection. CONCLUSIONS: R0 resection is associated with dramatic survival benefit over R1 resection in a subset of patients with tumor size ≤25 mm and ≤1 involved LN. These findings underscore the importance of R0 resection and careful patient selection for upfront surgery in patients with PaCa.
Collapse
Affiliation(s)
- Pavan Tummala
- Division of Gastroenterology and Hepatology, Saint Louis University School of Medicine, St Louis, Missouri, USA
| | | | | |
Collapse
|
13
|
|
14
|
Boyd CA, Branch DW, Sheffield KM, Han Y, Kuo YF, Goodwin JS, Riall TS. Hospital and medical care days in pancreatic cancer. Ann Surg Oncol 2012; 19:2435-42. [PMID: 22451235 PMCID: PMC3407309 DOI: 10.1245/s10434-012-2326-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND Little is known about resource utilization (number of days in the hospital or medical care) between diagnosis and death in patients with pancreatic cancer. METHODS Using Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data, we identified 25,476 patients with pancreatic cancer (1992-2005). Hospital and medical care days per person-month from the time of diagnosis were described, stratified by stage, treatment, and survival duration. RESULTS Hospital/medical care days vary by length of survival and treatment strategy in patients with pancreatic cancer. For all stages, patients were in the hospital a mean of 6.4 days and received medical care a total of 9.0 days in the first month after diagnosis, decreasing to 1.7 and 3.7 days per month, respectively, by the end of the first year. Hospital/medical care days per month of life were higher in patients with shorter survival but increased sharply at the end of life in all patients, regardless of duration of survival. In patients with locoregional disease, resection was associated with a higher number of hospital/medical care days during the first 4 months after diagnosis, but fewer at the end of the first year. For distant disease, hospital days were similar but days in medical care were higher for patients receiving chemotherapy, increasing especially at the end of life. CONCLUSIONS This study is the first to quantify hospital/medical care days in patients with pancreatic cancer by stage, treatment, and survival. This information will provide realistic expectations and allow for treatment decisions based on patient preferences.
Collapse
Affiliation(s)
- Casey A Boyd
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX, USA.
| | | | | | | | | | | | | |
Collapse
|
15
|
Riall TS, Brown KM. Individualizing care for locoregional pancreatic cancer? J Surg Res 2012; 179:41-4. [PMID: 22221606 DOI: 10.1016/j.jss.2011.10.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Revised: 10/13/2011] [Accepted: 10/26/2011] [Indexed: 11/16/2022]
Affiliation(s)
- Taylor S Riall
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX 77555-0541, USA.
| | | |
Collapse
|
16
|
Abstract
Robotic-assisted major pancreatic resections allow recreation of time-tested open surgical procedures on a minimally invasive platform. Early outcomes from robotic-assisted major pancreatic resections are comparable with those of laparoscopic and open approaches. Robotic assistance has the potential to bring the well-recognized advantages of minimally invasive surgery to major pancreatic resections. Technological innovations and increased surgeon familiarity with this approach will improve, likely leading to greater adoption and acceptance.
Collapse
Affiliation(s)
- H J Zeh
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh School of Medicine, Suite 417, UPMC Cancer Pavilion, 5150 Center Avenue, Pittsburgh, PA 15232, USA.
| | | | | |
Collapse
|
17
|
Zeh HJ, Zureikat AH, Secrest A, Dauoudi M, Bartlett D, Moser AJ. Outcomes after robot-assisted pancreaticoduodenectomy for periampullary lesions. Ann Surg Oncol 2011; 19:864-70. [PMID: 21947670 DOI: 10.1245/s10434-011-2045-0] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Indexed: 12/17/2022]
Abstract
BACKGROUND There are many theoretical advantages that a minimally invasive approach to the pancreaticoduodenectomy might offer patients with benign and malignant disease of the head of the pancreas over traditional open techniques, including improved recovery time, decreased hospital stay, and earlier initiation of and higher rate of completion of adjuvant therapy. The goal of this study was to assess the oncologic and safety outcomes after a robot-assisted approach to pancreaticoduodenectomy. METHODS Retrospective review of a prospectively acquired database of robot-assisted pancreaticoduodenectomy (RAPD) for periampullary lesions between October 2008 and December 2010. RESULTS Fifty patients underwent attempted RAPD. Conversion to open procedure was required in eight patients (16%). At intention-to-treat analysis, pancreatic fistula as defined by the International Study Group of Pancreatic Surgery occurred in 10 patients (20%). Most patients experienced either no (21, 42%) postoperative complications or minor Clavien I/II events (13, 26%). Major morbidity (Clavien III/IV) occurred in 15 patients (30%). The margin-negative resection rate was 89%, and the median number of lymph nodes collected was 18. Fifteen patients met the eligibility criteria for adjuvant chemotherapy after surgery. Eleven (73.3%) of 15 eligible patients were treated with adjuvant therapy at a mean of 11.5 weeks after surgery. CONCLUSIONS RAPD can be performed with safety and oncologic outcomes comparable to open or laparoscopic approaches. Results of this early series suggest that the robot-assisted approach holds promise. Larger, more mature multi-institutional cohorts will be needed to explore potential benefits over open and laparoscopic techniques.
Collapse
Affiliation(s)
- Herbert J Zeh
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
| | | | | | | | | | | |
Collapse
|
18
|
Zureikat AH, Breaux JA, Steel JL, Hughes SJ. Can laparoscopic pancreaticoduodenectomy be safely implemented? J Gastrointest Surg 2011; 15:1151-7. [PMID: 21538192 DOI: 10.1007/s11605-011-1530-x] [Citation(s) in RCA: 121] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Accepted: 04/01/2011] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The implementation of laparoscopic pancreaticoduodenectomy (LPD) has been appropriately met with apprehension, and concerns exist regarding outcomes early in a program's experience. We reviewed our early experience and outcomes of LPD. METHODS A retrospective review of patients undergoing LPD was compared to a matched cohort of open pancreaticoduodenectomy (OPD) patients. The endpoints are as follows: age, gender, ASA score, BMI, operative time, estimated blood loss, perioperative transfusion requirement, intensive care unit stay, margin status, lymph node count, 90 day morbidity and mortality, length of stay, and adjuvant therapy treatment. RESULTS Fourteen patients underwent an attempted LPD. The median operative time was 456 min (interquartile range (IQR), 109.5), median estimated blood loss was 300 ml (IQR, 225), and 29% of the patients required a perioperative blood transfusion. A conversion was necessary in two patients (14%). A malignancy was present in 12 patients. The mean tumor size was 2.2 cm (standard deviation (SD), 1.1), the mean lymph node count was 18.5 (SD 6.2), and an R0 resection was achieved in all 12 cases. Clavien grade I/II complications occurred in 42% of the patients, and Clavien grade III/IV complications occurred in three (20%). There was one late postoperative death. The median length of stay was 8 days. Compared to OPD, LPD took longer to perform, but no differences were noted with respect to blood loss, morbidity, mortality, R0 resection rate, and LN harvest. CONCLUSIONS LPD can be implemented in a high-volume pancreatic surgery center with acceptable oncologic and patient outcomes.
Collapse
Affiliation(s)
- Amer H Zureikat
- Department of Surgery, Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | | | | |
Collapse
|
19
|
Bao PQ, Ramanathan RK, Krasinkas A, Bahary N, Lembersky BC, Bartlett DL, Hughes SJ, Lee KK, Moser AJ, Zeh HJ. Phase II study of gemcitabine and erlotinib as adjuvant therapy for patients with resected pancreatic cancer. Ann Surg Oncol 2010; 18:1122-9. [PMID: 21104328 DOI: 10.1245/s10434-010-1401-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2010] [Indexed: 12/11/2022]
Abstract
BACKGROUND There is currently no consensus about the most effective adjuvant therapy for adenocarcinoma of the pancreas. Both gemcitabine and erlotinib have been demonstrated to improve survival in patients with metastatic disease. This study was designed to evaluate the efficacy of gemcitabine and erlotinib as adjuvant therapy, and to explore potential biomarkers associated with response. METHODS An institutional review board-approved single-center phase II trial of adjuvant biweekly fixed-dose rate gemcitabine (1500 mg/m(2)) and daily erlotinib (150 mg/day) for 4 months followed by maintenance erlotinib (150 mg/day) over 8 months was initiated. Primary end point was recurrence-free survival (RFS). Epidermal growth factor receptor (EGFR) expression in the resected tumors was assessed by fluorescence in situ hybridization (FISH) and immunohistochemistry (IHC). RESULTS The study completed planned accrual of 25 patients. Median follow-up was 18.2 (range 11.6-23.5) months. Recurrences were observed in 17 subjects (68%). Median RFS was 14.0 months (95% confidence interval [95% CI], 8.2-24.5) with 1-year and 2-year RFS of 56% (95% CI, 35-73) and 26% (95% CI, 6-52), respectively. Median overall survival was not reached. Estimated 1-year and 2-year overall survival was 84% (95% CI, 63-94) and 53% (95% CI, 22-76), respectively. Nine patients (36%) had a grade 3 event and only 1 (4%) had a grade 4 (neutropenia). Most toxicities were dermatologic, gastrointestinal, and constitutional. There were nonsignificant trends to longer RFS and lower recurrence rates while receiving therapy in subjects with fluorescence in situ hybridization-positive tumors and greater immunohistochemistry expression. CONCLUSIONS Our phase II results suggest that adjuvant gemcitabine and erlotinib is a promising regimen that merits further investigation.
Collapse
Affiliation(s)
- Philip Q Bao
- Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|