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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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Rompen IF, Levine J, Habib JR, Sereni E, Mughal N, Hewitt DB, Sacks GD, Welling TH, Simeone DM, Kaplan B, Berman RS, Cohen SM, Wolfgang CL, Javed AA. Progression of Site-specific Recurrence of Pancreatic Cancer and Implications for Treatment. Ann Surg 2024; 280:317-324. [PMID: 37870253 PMCID: PMC11259998 DOI: 10.1097/sla.0000000000006142] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
OBJECTIVE To analyze postrecurrence progression in the context of recurrence sites and assess implications for postrecurrence treatment. BACKGROUND Most patients with resected pancreatic ductal adenocarcinoma (PDAC) recur within 2 years. Different survival outcomes for location-specific patterns of recurrence are reported, highlighting their prognostic value. However, a lack of understanding of postrecurrence progression and survival remains. METHODS This retrospective analysis included surgically treated patients with PDAC at NYU Langone Health (2010-2021). Sites of recurrence were identified at the time of diagnosis and further follow-up. Kaplan-Meier curves, log-rank test, and Cox regression analyses were applied to assess survival outcomes. RESULTS Recurrence occurred in 57.3% (196/342) patients with a median time to recurrence of 11.3 months (95% CI: 12.6-16.5). The first site of recurrence was local in 43.9% of patients, liver in 23.5%, peritoneal in 8.7%, lung in 3.6%, whereas 20.4% had multiple sites of recurrence. Progression to secondary sites was observed in 11.7%. Only lung involvement was associated with significantly longer survival after recurrence compared with other sites (16.9 vs 8.49 months, P = 0.003). In local recurrence, 21 (33.3%) patients were alive after 1 year without progression to secondary sites. This was associated with a CA19-9 of <100 U/mL at the time of primary diagnosis ( P = 0.039), nodal negative disease ( P = 0.023), and well-moderate differentiation ( P = 0.042) compared with patients with progression. CONCLUSION Except for lung recurrence, postrecurrence survival after PDAC resection is associated with poor survival. A subset of patients with local-only recurrence do not quickly succumb to systemic spread. This is associated with markers for favorable tumor biology, making them candidates for potential curative re-resections when feasible.
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Affiliation(s)
- Ingmar F. Rompen
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Jonah Levine
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Joseph R. Habib
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Elisabetta Sereni
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Nabiha Mughal
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - D. Brock Hewitt
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Greg D. Sacks
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Theodore H. Welling
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Diane M. Simeone
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Brian Kaplan
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Russell S. Berman
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Steven M. Cohen
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Christopher L. Wolfgang
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Ammar A. Javed
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, the Netherlands
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Poiset SJ, Shah S, Cappelli L, Anné P, Mooney KE, Werner-Wasik M, Laufer TS, Posey JA, Lin D, Basu Mallick A, Lavu H, Bashir B, Yeo CJ, Mueller AC. Early outcomes of MR-guided SBRT for patients with recurrent pancreatic adenocarcinoma. Radiat Oncol 2024; 19:65. [PMID: 38812040 PMCID: PMC11138072 DOI: 10.1186/s13014-024-02457-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 05/17/2024] [Indexed: 05/31/2024] Open
Abstract
BACKGROUND Local treatment options for locally recurrent pancreatic adenocarcinoma (LR-PAC) are limited, with median survival time (MST) of 9-13 months (mos) following recurrence. MRI-guided stereotactic body radiation therapy (MRgSBRT) provides the ability to dose escalate while sparing normal tissue. Here we report on the early outcomes of MRgSBRT for LR-PAC. METHODS Patients with prior resection of pancreatic adenocarcinoma with local recurrence treated with MRgSBRT at a single tertiary referral center from 5-2021 to 2-2023 were identified from our prospective database. MRgSBRT was delivered to 40-50 Gy in 4-5 fractions with target and OAR delineation per institutional standards. Endpoints included local control per RECIST v1.1, distant failure, overall survival (OS), and acute and chronic toxicities per Common Terminology Criteria for Adverse Events, v5. RESULTS Fifteen patients with LR-PAC were identified with median follow-up of 10.6 mos (2.8-26.5 mos) from MRgSBRT. There were 8 females and 7 males, with a median age of 69 years (50-83). One patient underwent neoadjuvant radiation for 50.4 Gy in 28 fractions followed by resection, and one underwent adjuvant radiation for 45 Gy in 25 fractions prior to recurrence. MRgSBRT was delivered a median of 18.8 mos (3.5-52.8 mos) following resection. OS following recurrence at 6 and 12 mos were 87% and 51%, respectively, with a median survival time of 14.1 mos (3.2-27.4 mos). Three patients experienced local failure at 5.9, 7.8, and 16.6 months from MgSBRT with local control of 92.3% and 83.9% at 6 and 12 months. 10 patients experienced distant failure at a median of 2.9 mos (0.3-6.7 mos). Grade 1-2 acute GI toxicity was noted in 47% of patients, and chronic GI toxicity in 31% of patients. No grade > 3 toxicities were noted. CONCLUSIONS This is the first report on toxicity and outcomes of MRgSBRT for LR-PAC in the literature. MRgSBRT is a safe, feasible treatment modality with the potential for improved local control in this vulnerable population. Future research is necessary to better identify which patients yield the most benefit from MRgSBRT, which should continue to be used with systemic therapy as tolerated. TRIAL REGISTRATION Jefferson IRB#20976, approved 2/17/21.
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Affiliation(s)
- Spencer J Poiset
- Department of Radiation Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, 111 S 11th St. Suite G301, Philadelphia, PA, 19107, USA
| | - Sophia Shah
- Department of Radiation Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, 111 S 11th St. Suite G301, Philadelphia, PA, 19107, USA
| | - Louis Cappelli
- Department of Radiation Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, 111 S 11th St. Suite G301, Philadelphia, PA, 19107, USA
| | - Pramila Anné
- Department of Radiation Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, 111 S 11th St. Suite G301, Philadelphia, PA, 19107, USA
| | - Karen E Mooney
- Department of Radiation Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, 111 S 11th St. Suite G301, Philadelphia, PA, 19107, USA
| | - Maria Werner-Wasik
- Department of Radiation Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, 111 S 11th St. Suite G301, Philadelphia, PA, 19107, USA
| | - Talya S Laufer
- Department of Radiation Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, 111 S 11th St. Suite G301, Philadelphia, PA, 19107, USA
| | - James A Posey
- Department of Medical Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, Philadelphia, PA, USA
| | - Daniel Lin
- Department of Medical Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, Philadelphia, PA, USA
| | - Atrayee Basu Mallick
- Department of Medical Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, Philadelphia, PA, USA
| | - Harish Lavu
- Department of Surgery, Sidney Kimmel Cancer Center of Thomas Jefferson University, Philadelphia, PA, USA
| | - Babar Bashir
- Department of Medical Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, Philadelphia, PA, USA
| | - Charles J Yeo
- Department of Surgery, Sidney Kimmel Cancer Center of Thomas Jefferson University, Philadelphia, PA, USA
| | - Adam C Mueller
- Department of Radiation Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, 111 S 11th St. Suite G301, Philadelphia, PA, 19107, USA.
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA.
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Lynch IT, Abdelrahman AM, Alva-Ruiz R, Fogliati A, Graham RP, Smoot R, Truty MJ. Cancer "Avatars": Patient-Derived Xenograft Growth Correlation with Postoperative Recurrence and Survival in Pancreaticobiliary Cancer. J Am Coll Surg 2023; 237:483-500. [PMID: 37326316 PMCID: PMC10417234 DOI: 10.1097/xcs.0000000000000786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/14/2023] [Accepted: 05/04/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND Pancreaticobiliary (PB) cancers are a diverse group of cancers with poor prognoses and high rates of recurrence after resection. Patient-derived xenografts (PDX), created from surgical specimens, provide a reliable preclinical research platform and high-fidelity cancer model from which to study these malignancies with consistent recapitulation of their original patient tumors in vivo. However, the relationship between PDX engraftment success (growth or no growth) and patient oncologic outcomes has not been well studied. We sought to evaluate the correlation between successful PDX engraftment and survival in several PB exocrine carcinomas, including the pancreatic and biliary tract. STUDY DESIGN In accordance with IRB and Institutional Animal Care and Use Committee protocols and with appropriate consent and approval, excess tumor tissue obtained from surgical patients was implanted into immunocompromised mice. Mice were monitored for tumor growth to determine engraftment success. PDX tumors were verified to recapitulate their tumors of origin by a hepatobiliary pathologist. Xenograft growth was correlated with clinical recurrence and overall survival data. RESULTS A total of 384 PB xenografts were implanted. The successful engraftment rate was 41% (158/384). We found that successful PDX engraftment was highly associated with both recurrence-free survival (p < 0.001) and overall survival (p < 0.001) outcomes. Successful PDX tumor generation occurs significantly in advance of clinical recurrences in their corresponding patients (p < 0.001). CONCLUSIONS Successful PB cancer PDX models predict recurrence and survival across tumor types and may provide critical lead time to alter patients' surveillance or treatment plans before cancer recurrence.
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Affiliation(s)
- Isaac T Lynch
- From the Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN (Lynch, Abdelrahman, Alva-Ruiz, Fogliati, Smoot, Truty)
| | - Amro M Abdelrahman
- From the Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN (Lynch, Abdelrahman, Alva-Ruiz, Fogliati, Smoot, Truty)
| | - Roberto Alva-Ruiz
- From the Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN (Lynch, Abdelrahman, Alva-Ruiz, Fogliati, Smoot, Truty)
| | - Alessandro Fogliati
- From the Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN (Lynch, Abdelrahman, Alva-Ruiz, Fogliati, Smoot, Truty)
| | - Rondell P Graham
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN (Graham)
| | - Rory Smoot
- From the Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN (Lynch, Abdelrahman, Alva-Ruiz, Fogliati, Smoot, Truty)
| | - Mark J Truty
- From the Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN (Lynch, Abdelrahman, Alva-Ruiz, Fogliati, Smoot, Truty)
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Słodkowski M, Wroński M, Karkocha D, Kraj L, Śmigielska K, Jachnis A. Current Approaches for the Curative-Intent Surgical Treatment of Pancreatic Ductal Adenocarcinoma. Cancers (Basel) 2023; 15:cancers15092584. [PMID: 37174050 PMCID: PMC10177138 DOI: 10.3390/cancers15092584] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 04/24/2023] [Accepted: 04/28/2023] [Indexed: 05/15/2023] Open
Abstract
Radical resection is the only curative treatment for pancreatic cancer. However, only up to 20% of patients are considered eligible for surgical resection at the time of diagnosis. Although upfront surgery followed by adjuvant chemotherapy has become the gold standard of treatment for resectable pancreatic cancer there are numerous ongoing trials aiming to compare the clinical outcomes of various surgical strategies (e.g., upfront surgery or neoadjuvant treatment with subsequent resection). Neoadjuvant treatment followed by surgery is considered the best approach in borderline resectable pancreatic tumors. Individuals with locally advanced disease are now candidates for palliative chemo- or chemoradiotherapy; however, some patients may become eligible for resection during the course of such treatment. When metastases are found, the cancer is qualified as unresectable. It is possible to perform radical pancreatic resection with metastasectomy in selected cases of oligometastatic disease. The role of multi-visceral resection, which involves reconstruction of major mesenteric veins, is well known. Nonetheless, there are some controversies in terms of arterial resection and reconstruction. Researchers are also trying to introduce personalized treatments. The careful, preliminary selection of patients eligible for surgery and other therapies should be based on tumor biology, among other factors. Such selection may play a key role in improving survival rates in patients with pancreatic cancer.
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Affiliation(s)
- Maciej Słodkowski
- Department of General, Gastroenterologic and Oncologic Surgery, Medical University of Warsaw, 02-097 Warsaw, Poland
- Department of Molecular Biology, Institute of Genetics and Animal Biotechnology, Polish Academy of Sciences, 05-552 Jastrzębiec, Poland
| | - Marek Wroński
- Department of General, Gastroenterologic and Oncologic Surgery, Medical University of Warsaw, 02-097 Warsaw, Poland
| | - Dominika Karkocha
- Department of General, Gastroenterologic and Oncologic Surgery, Medical University of Warsaw, 02-097 Warsaw, Poland
| | - Leszek Kraj
- Department of Molecular Biology, Institute of Genetics and Animal Biotechnology, Polish Academy of Sciences, 05-552 Jastrzębiec, Poland
- Department of Oncology, Medical University of Warsaw, 02-097 Warsaw, Poland
| | - Kaja Śmigielska
- Department of General, Gastroenterologic and Oncologic Surgery, Medical University of Warsaw, 02-097 Warsaw, Poland
| | - Aneta Jachnis
- Department of General, Gastroenterologic and Oncologic Surgery, Medical University of Warsaw, 02-097 Warsaw, Poland
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Kornmann M, Kleger A. Editorial: Multimodality Treatment in Pancreatic Ductal Adenocarcinoma - Current Options and the Future Impact of Molecular Biological Profiling. Visc Med 2022; 38:1-3. [PMID: 35291696 PMCID: PMC8874236 DOI: 10.1159/000521419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 12/08/2021] [Indexed: 08/25/2024] Open
Affiliation(s)
- Marko Kornmann
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Ulm, Ulm, Germany
| | - Alexander Kleger
- Klinik für Innere Medizin I, Universitätsklinikum Ulm, Ulm, Germany
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