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Hammad A, Davis LE, Mahar AL, Bubis LD, Zhao H, Earle CC, Barbera L, Hallet J, Coburn NG. Symptom trajectories and predictors of severe symptoms in pancreatic adenocarcinoma at the end-of-life: a population based analysis of 2,538 patients. HPB (Oxford) 2019; 21:1744-1752. [PMID: 31300337 DOI: 10.1016/j.hpb.2019.04.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 02/11/2019] [Accepted: 04/17/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND We evaluated symptom trajectories and predictors of reporting severe symptoms in the last 6 months of life among non-resected pancreatic adenocarcinoma (PAC) decedents. METHODS A retrospective cohort study of non-resected PAC decedents receiving care at regional cancer centres between January 2007 and December 2015. Symptoms were measured using the Edmonton Symptom Assessment System (ESAS). We described the proportion of patients reporting severe (score ≥7) symptoms by 2-week intervals during the six months prior to death. Multivariable modified Poisson regression models identified predictors of reporting severe symptom scores in the last 6 months of life. RESULTS 2538 non-resected PAC decedents treated at regional cancer centres had ≥1 symptom ESAS record in the last six months of life, totaling 10,893 unique symptom assessments. Tiredness was the most commonly reported symptom (59% reporting ≥1 severe score), followed by lack of appetite (57%), impaired-wellbeing (49%) and drowsiness (42%). All symptoms increased closer to death. Older age, female sex, higher comorbidity status, survival less than 6 months, and urban residence were associated with a significantly higher risk of reporting severe symptoms. CONCLUSION Non-resected PAC patients experience significant symptom burden nearing death. Patient subsets may benefit from personalized supportive care interventions.
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Affiliation(s)
- Ahmed Hammad
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of General Surgery, Mansoura University Hospitals, Mansoura, Egypt; ICES, Toronto, Canada
| | - Laura E Davis
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Alyson L Mahar
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Lev D Bubis
- Department of Surgery, University of Toronto, Canada
| | | | - Craig C Earle
- ICES, Toronto, Canada; Division of Medical Oncology, Odette Cancer Centre - Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Lisa Barbera
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada; ICES, Toronto, Canada; Division of Radiation Oncology, Department of Oncology, University of Calgary
| | - Julie Hallet
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada; ICES, Toronto, Canada; Department of Surgery, University of Toronto, Canada; Division of General Surgery, Odette Cancer Centre - Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Natalie G Coburn
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada; ICES, Toronto, Canada; Department of Surgery, University of Toronto, Canada; Division of General Surgery, Odette Cancer Centre - Sunnybrook Health Sciences Centre, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
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Scott SJ, Adams MS, Salgaonkar V, Sommer FG, Diederich CJ. Theoretical investigation of transgastric and intraductal approaches for ultrasound-based thermal therapy of the pancreas. J Ther Ultrasound 2017; 5:10. [PMID: 28469915 PMCID: PMC5414307 DOI: 10.1186/s40349-017-0090-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 02/07/2017] [Indexed: 02/07/2023] Open
Abstract
Background The goal of this study was to theoretically investigate the feasibility of intraductal and transgastric approaches to ultrasound-based thermal therapy of pancreatic tumors, and to evaluate possible treatment strategies. Methods This study considered ultrasound applicators with 1.2 mm outer diameter tubular transducers, which are inserted into the tissue to be treated by an endoscopic approach, either via insertion through the gastric wall (transgastric) or within the pancreatic duct lumen (intraductal). 8 patient-specific, 3D, transient, biothermal and acoustic finite element models were generated to model hyperthermia (n = 2) and ablation (n = 6), using sectored (210°–270°, n = 4) and 360° (n = 4) transducers for treatment of 3.3–17.0 cm3 tumors in the head (n = 5), body (n = 2), and tail (n = 1) of the pancreas. A parametric study was performed to determine appropriate treatment parameters as a function of tissue attenuation, blood perfusion rates, and distance to sensitive anatomy. Results Parametric studies indicated that pancreatic tumors up to 2.5 or 2.7 cm diameter can be ablated within 10 min with the transgastric and intraductal approaches, respectively. Patient-specific simulations demonstrated that 67.1–83.3% of the volumes of four sample 3.3–11.4 cm3 tumors could be ablated within 3–10 min using transgastric or intraductal approaches. 55.3–60.0% of the volume of a large 17.0 cm3 tumor could be ablated using multiple applicator positions within 20–30 min with either transgastric or intraductal approaches. 89.9–94.7% of the volume of two 4.4–11.4 cm3 tumors could be treated with intraductal hyperthermia. Sectored applicators are effective in directing acoustic output away from and preserving sensitive structures. When acoustic energy is directed towards sensitive structures, applicators should be placed at least 13.9–14.8 mm from major vessels like the aorta, 9.4–12.0 mm from other vessels, depending on the vessel size and flow rate, and 14 mm from the duodenum. Conclusions This study demonstrated the feasibility of generating shaped or conformal ablative or hyperthermic temperature distributions within pancreatic tumors using transgastric or intraductal ultrasound.
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Affiliation(s)
- Serena J Scott
- Department of Radiation Oncology, Thermal Therapy Research Group, University of California, San Francisco, 1600 Divisadero Street, Suite H1031, San Francisco, CA 94143-1708 USA
| | - Matthew S Adams
- Department of Radiation Oncology, Thermal Therapy Research Group, University of California, San Francisco, 1600 Divisadero Street, Suite H1031, San Francisco, CA 94143-1708 USA.,UC Berkeley - UC San Francisco Graduate Program in Bioengineering, California, USA
| | - Vasant Salgaonkar
- Department of Radiation Oncology, Thermal Therapy Research Group, University of California, San Francisco, 1600 Divisadero Street, Suite H1031, San Francisco, CA 94143-1708 USA
| | - F Graham Sommer
- Department of Radiology, Stanford University School of Medicine, Stanford, CA USA
| | - Chris J Diederich
- Department of Radiation Oncology, Thermal Therapy Research Group, University of California, San Francisco, 1600 Divisadero Street, Suite H1031, San Francisco, CA 94143-1708 USA.,UC Berkeley - UC San Francisco Graduate Program in Bioengineering, California, USA
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Lee TH, Jang BS, Jung MK, Pack CG, Choi JH, Park DH. Fabrication of a silver particle-integrated silicone polymer-covered metal stent against sludge and biofilm formation and stent-induced tissue inflammation. Sci Rep 2016; 6:35446. [PMID: 27739486 PMCID: PMC5064322 DOI: 10.1038/srep35446] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 09/29/2016] [Indexed: 12/19/2022] Open
Abstract
To reduce tissue or tumor ingrowth, covered self-expandable metal stents (SEMSs) have been developed. The effectiveness of covered SEMSs may be attenuated by sludge or stone formation or by stent clogging due to the formation of biofilm on the covering membrane. In this study, we tested the hypothesis that a silicone membrane containing silver particles (Ag-P) would prevent sludge and biofilm formation on the covered SEMS. In vitro, the Ag-P-integrated silicone polymer-covered membrane exhibited sustained antibacterial activity, and there was no definite release of silver ions from the Ag-P-integrated silicone polymer membrane at any time point. Using a porcine stent model, in vivo analysis demonstrated that the Ag-P-integrated silicone polymer-covered SEMS reduced the thickness of the biofilm and the quantity of sludge formed, compared with a conventional silicone-covered SEMS. In vivo, the release of silver ions from an Ag-P-integrated silicone polymer-covered SEMS was not detected in porcine serum. The Ag-P-integrated silicone polymer-covered SEMS also resulted in significantly less stent-related bile duct and subepithelium tissue inflammation than a conventional silicone polymer-covered SEMS. Therefore, the Ag-P-integrated silicone polymer-covered SEMS reduced sludge and biofilm formation and stent-induced pathological changes in tissue. This novel SEMS may prolong the stent patency in clinical application.
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Affiliation(s)
- Tae Hoon Lee
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan, South Korea
| | - Bong Seok Jang
- R&D Institute of Intervention, M. I. Tech Co., Ltd., 174 Habuk 2gil, Jinwi-myeon, Pyeongtaek, Gyeonggi-do, 451-864, South Korea
| | - Min Kyo Jung
- Department of Convergence Medicine, University of Ulsan College of Medicine &Asan Institute for Life Sciences, Asan Medical Center, Seoul, South Korea.,School of Life Sciences and Biotechnology, Korea University, Seoul, Korea
| | - Chan Gi Pack
- Department of Convergence Medicine, University of Ulsan College of Medicine &Asan Institute for Life Sciences, Asan Medical Center, Seoul, South Korea
| | - Jun-Ho Choi
- Department of Internal Medicine, Dankook University Hospital, Dankook University College of Medicine, Cheonan, South Korea
| | - Do Hyun Park
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43 gil, Songpa-gu, Seoul 05505, South Korea
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Adams MS, Scott SJ, Salgaonkar VA, Sommer G, Diederich CJ. Thermal therapy of pancreatic tumours using endoluminal ultrasound: Parametric and patient-specific modelling. Int J Hyperthermia 2016; 32:97-111. [PMID: 27097663 DOI: 10.3109/02656736.2015.1119892] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE The aim of this study is to investigate endoluminal ultrasound applicator configurations for volumetric thermal ablation and hyperthermia of pancreatic tumours using 3D acoustic and biothermal finite element models. MATERIALS AND METHODS Parametric studies compared endoluminal heating performance for varying applicator transducer configurations (planar, curvilinear-focused, or radial-diverging), frequencies (1-5 MHz), and anatomical conditions. Patient-specific pancreatic head and body tumour models were used to evaluate feasibility of generating hyperthermia and thermal ablation using an applicator positioned in the duodenal or stomach lumen. Temperature and thermal dose were calculated to define ablation (> 240 EM(43 °C)) and moderate hyperthermia (40-45 °C) boundaries, and to assess sparing of sensitive tissues. Proportional-integral control was incorporated to regulate maximum temperature to 70-80 °C for ablation and 45 °C for hyperthermia in target regions. RESULTS Parametric studies indicated that 1-3 MHz planar transducers are the most suitable for volumetric ablation, producing 5-8 cm(3) lesion volumes for a stationary 5-min sonication. Curvilinear-focused geometries produce more localised ablation to 20-45 mm depth from the GI tract and enhance thermal sparing (T(max) < 42 °C) of the luminal wall. Patient anatomy simulations show feasibility in ablating 60.1-92.9% of head/body tumour volumes (4.3-37.2 cm(3)) with dose < 15 EM(43 °C) in the luminal wall for 18-48 min treatment durations, using 1-3 applicator placements in GI lumen. For hyperthermia, planar and radial-diverging transducers could maintain up to 8 cm(3) and 15 cm(3) of tissue, respectively, between 40-45 °C for a single applicator placement. CONCLUSIONS Modelling studies indicate the feasibility of endoluminal ultrasound for volumetric thermal ablation or hyperthermia treatment of pancreatic tumour tissue.
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Affiliation(s)
- Matthew S Adams
- a Thermal Therapy Research Group, University of California , San Francisco , California .,b University of California, Berkeley - University of California, San Francisco Graduate Program in Bioengineering , California , and
| | - Serena J Scott
- a Thermal Therapy Research Group, University of California , San Francisco , California
| | - Vasant A Salgaonkar
- a Thermal Therapy Research Group, University of California , San Francisco , California
| | - Graham Sommer
- c Stanford Medical Center , Stanford , California , USA
| | - Chris J Diederich
- a Thermal Therapy Research Group, University of California , San Francisco , California .,b University of California, Berkeley - University of California, San Francisco Graduate Program in Bioengineering , California , and
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Roy BT, Roy RB. Metastatic pancreatic cancer: abdominal pain in a 22-year-old woman. BMJ Case Rep 2015; 2015:bcr-2015-211361. [PMID: 26611479 DOI: 10.1136/bcr-2015-211361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Pancreatic cancer remains fourth among cancer-related deaths. Its diagnosis is often missed, owing to its vague abdominal symptoms, leading to a diagnosis of stage IV pancreatic cancer. FOLFIRINOX chemotherapy was administered to the patient in this report, resulting in significant improvement based on tests of biological markers as well as radiographic resolution of the metastatic disease. A keen awareness of this condition along with appropriate diagnostic tests can allow for an earlier diagnosis and may impact its high mortality.
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Affiliation(s)
- Bakul T Roy
- Department of Internal Medicine, Roy Medical Associates, Inc, San Ramon, California, USA
| | - Roshan B Roy
- Roy Medical Associates, Inc, San Ramon, California, USA
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Mellon EA, Hoffe SE, Springett GM, Frakes JM, Strom TJ, Hodul PJ, Malafa MP, Chuong MD, Shridhar R. Long-term outcomes of induction chemotherapy and neoadjuvant stereotactic body radiotherapy for borderline resectable and locally advanced pancreatic adenocarcinoma. Acta Oncol 2015; 54:979-85. [PMID: 25734581 DOI: 10.3109/0284186x.2015.1004367] [Citation(s) in RCA: 170] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE Limited data are available to guide neoadjuvant treatment of borderline resectable (BRPC) and locally advanced (LAPC) pancreatic cancer. MATERIAL AND METHODS We updated our institutional outcomes with a neoadjuvant chemotherapy and stereotactic body radiotherapy (SBRT) approach. An IRB-approved analysis was performed of all BRPC and LAPC patients treated with our departmental treatment protocol. After staging, medically fit patients underwent chemotherapy for 2-3 months, with regimen at the discretion of the treating medical oncologist. Patients then received SBRT delivered in five consecutive daily fractions with median total radiation doses of 30 Gy to tumor and 40 Gy dose painted to tumor-vessel interfaces. This was followed by restaging imaging for possible resection. Overall survival (OS), event free survival (EFS), and locoregional control (LRC) rates were estimated and compared by Kaplan-Meier and log-rank methods. RESULTS We identified 159 patients, 110 BRPC and 49 LAPC, with 14.0 months median overall follow-up. The resection and margin negative (R0) rate for BRPC patients who completed neoadjuvant therapy was 51% and 96%, respectively. Estimated median OS was 19.2 months for BRPC patients and 15.0 months for LAPC patients (p = 0.402). Median OS was 34.2 months for surgically resected patients versus 14.0 months for unresected patients (p < 0.001). Five of 21 (24%) LAPC patients receiving FOLFIRINOX chemotherapy underwent R0 resection. In LAPC, FOLFIRINOX recipients underwent R0 resection more often than other chemotherapy recipients (5 of 21 vs. 0 of 28, p = 0.011). There was a trend for improved survival in those resected LAPC patients (p = 0.09). For those not undergoing resection, one year LRC was 78%. Any grade ≥ 3 potentially radiation-related toxicity rate was 7%. CONCLUSIONS These data underscore the feasibility, safety, and effectiveness of neoadjuvant SBRT and chemotherapy for BRPC and LAPC.
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Affiliation(s)
- Eric A. Mellon
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Sarah E. Hoffe
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Gregory M. Springett
- Gastrointestinal Tumor Program, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Jessica M. Frakes
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Tobin J. Strom
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Pamela J. Hodul
- Gastrointestinal Tumor Program, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Mokenge P. Malafa
- Gastrointestinal Tumor Program, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Michael D. Chuong
- Department of Radiation Oncology, University of Maryland, Baltimore, Maryland, USA
| | - Ravi Shridhar
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
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A prospective, randomized, double-blind, placebo controlled trial on the efficacy of ethanol celiac plexus neurolysis in patients with operable pancreatic and periampullary adenocarcinoma. J Am Coll Surg 2014; 220:497-508. [PMID: 25667135 PMCID: PMC4448126 DOI: 10.1016/j.jamcollsurg.2014.12.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Accepted: 12/09/2014] [Indexed: 12/16/2022]
Abstract
Background Ethanol celiac plexus neurolysis (ECPN) has been shown to be effective in reducing cancer-related pain in patients with locally advanced pancreatic and periampullary adenocarcinoma (PPA). This study examined its efficacy in patients undergoing PPA resection. Study Design 485 patients participated in this prospective, randomized, double blind placebo controlled trial. Patients were stratified by preoperative pain and disease resectability. They received either ECPN (50% ethanol) or 0.9% normal saline placebo control. The primary endpoint was short and long-term pain and secondary endpoints included postoperative morbidity, QOL and overall survival. Results Data from 467 patients were analyzed. The primary endpoint, the percentage of PPA patients experiencing a worsening of pain compared to preoperative baseline for resectable patients, was not different between the ethanol and saline groups in either the resectable/pain stratum (22% vs 18%, RR 1.23 (0.34, 4.46)), or the resectable/no pain stratum (37% vs 34%, RR 1.10 (0.67, 1.81)). On multivariable analysis of resected pancreatic ductal adenocarcinoma (PDA) patients, there was a significant reduction in pain in the resectable/pain group, suggesting that surgical resection of the malignancy alone (independent of ECPN) decrements pain to a significant degree. Conclusions In this study, we have demonstrated a significant reduction in pain following surgical resection of PPA. However the addition of ECPN did not synergize to result in a further reduction in pain, and in fact its effect may have been masked by surgical resection. Given this, we cannot recommend the use of ECPN to mitigate cancer related pain in resectable PPA patients.
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Sherwood P, Given BA, Given CW, Champion VL, Doorenbos AZ, Azzouz F, Kozachik S, Wagler-Ziner K, Monahan PO. A cognitive behavioral intervention for symptom management in patients with advanced cancer. Oncol Nurs Forum 2005; 32:1190-8. [PMID: 16270114 PMCID: PMC1805479 DOI: 10.1188/05.onf.1190-1198] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE/OBJECTIVES To evaluate the effectiveness of a cognitive behavioral intervention in decreasing symptom severity in patients with advanced cancer undergoing chemotherapy. DESIGN Prospective, randomized clinical trial based on cognitive behavioral theory. SETTING Six urban cancer centers in the midwestern United States. SAMPLE 124 patients 21 years of age or older were recruited and randomized to receive conventional care or conventional care and an intervention. Participants were newly diagnosed with stage III, stage IV, or recurrent cancer (solid tumor or non-Hodgkin lymphoma), undergoing chemotherapy, cognitively intact, and able to read and speak English. METHODS Data were gathered via telephone interviews at baseline and 10 and 20 weeks after randomization. Nurses with experience in oncology delivered a five-contact, eight-week intervention aimed at teaching patients problem-solving techniques to affect symptom severity. MAIN RESEARCH VARIABLES Gender, site of cancer, age, symptom severity and depressive symptoms at baseline, group (i.e., experimental versus control), and total symptom severity. FINDINGS Patients in the experimental group and those with lower symptom severity at baseline had significantly lower symptom severity at 10 and 20 weeks; the experimental difference at 20 weeks occurred primarily in those 60 years of age and younger. Depressive symptoms at baseline predicted symptom severity at 20 weeks; however, age, gender, and site of cancer did not affect symptom severity at either time point. CONCLUSIONS A cognitive behavioral intervention to teach problem-solving skills can be effective for patient symptom self-management during and following an intervention. IMPLICATIONS FOR NURSING Problem-solving strategies should be included in educational programs for patients with advanced cancer, particularly those 60 years of age and younger.
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Affiliation(s)
- Paula Sherwood
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA.
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N/A. N/A. Shijie Huaren Xiaohua Zazhi 2004; 12:2671-2673. [DOI: 10.11569/wcjd.v12.i11.2671] [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: 02/06/2023] Open
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