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Lindemann J, du Toit L, Kotze U, Bernon M, Krige J, Jonas E. Survival equivalence in patients treated for borderline resectable and unresectable locally advanced pancreatic ductal adenocarcinoma: a systematic review and network meta-analysis. HPB (Oxford) 2021; 23:173-186. [PMID: 33268268 DOI: 10.1016/j.hpb.2020.09.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/04/2020] [Accepted: 09/29/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The clinical relevance of subdivision of non-metastatic pancreatic ductal adenocarcinoma (PDAC) into locally advanced borderline resectable (LA-BR) and locally advanced unresectable (LA-UR) has been questioned. We assessed equivalence of overall survival (OS) in patients with LA-BR and LA-UR PDAC. METHODS A systematic review was performed of studies published January 1, 2009 to August 21, 2019, reporting OS for LA-BR and LA-UR patients treated with or without neoadjuvant therapy (NAT), with or without surgical resection. A frequentist network meta-analysis was used to assess the primary outcome (hazard ratio for OS) and secondary outcomes (OS in LA-BR, LA-UR, and upfront resectable (UFR) PDAC). RESULTS Thirty-nine studies, comprising 14,065 patients in a network of eight unique treatment subgroups were analysed. Overall survival was better for LA-BR than LA-UR patients following surgery both with and without NAT. Neoadjuvant therapy prior to surgery was associated with longer OS for UFR, LA-BR, and LA-UR tumours, compared to upfront surgery. CONCLUSION Survival between the LA-BR and LA-UR subgroups was not equivalent. This subdivision is useful for prognostication, but likely unhelpful in treatment decision making. Our data supports NAT regardless of initial disease extent. Individual patient data assessment is needed to accurately estimate the benefit of NAT.
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Affiliation(s)
- Jessica Lindemann
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa; Department of Surgery, Washington University School of Medicine, 660 South Euclid Ave, Saint Louis, MO, 63110, USA
| | - Leon du Toit
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Urda Kotze
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Marc Bernon
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Jake Krige
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Eduard Jonas
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa.
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Bradley A, Van Der Meer R. Neoadjuvant therapy versus upfront surgery for potentially resectable pancreatic cancer: A Markov decision analysis. PLoS One 2019; 14:e0212805. [PMID: 30817807 PMCID: PMC6394923 DOI: 10.1371/journal.pone.0212805] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 02/09/2019] [Indexed: 12/16/2022] Open
Abstract
Background Neoadjuvant therapy has emerged as an alternative treatment strategy for potentially resectable pancreatic cancer. In the absence of large randomized controlled trials offering a direct comparison, this study aims to use Markov decision analysis to compare efficacy of traditional surgery first (SF) and neoadjuvant treatment (NAT) pathways for potentially resectable pancreatic cancer. Methods An advanced Markov decision analysis model was constructed to compare SF and NAT pathways for potentially resectable pancreatic cancer. Transition probabilities were calculated from randomized control and Phase II/III trials after comprehensive literature search. Utility outcomes were measured in overall and quality-adjusted life months (QALMs) on an intention-to-treat basis as the primary outcome. Markov cohort analysis of treatment received was the secondary outcome. Model uncertainties were tested with one and two-way deterministic and probabilistic Monte Carlo sensitivity analysis. Results SF gave 23.72 months (18.51 QALMs) versus 20.22 months (16.26 QALMs). Markov Cohort Analysis showed that where all treatment modalities were received NAT gave 35.05 months (29.87 QALMs) versus 30.96 months (24.86QALMs) for R0 resection and 34.08 months (29.87 QALMs) versus 25.85 months (20.72 QALMs) for R1 resection. One-way deterministic sensitivity analysis showed that NAT was superior if the resection rate was greater than 51.04% or below 75.68% in SF pathway. Two-way sensitivity analysis showed that pathway superiority depended on obtaining multimodal treatment in either pathway. Conclusion Whilst NAT is a viable alternative to traditional SF approach, superior pathway selection depends on the individual patient’s likelihood of receiving multimodal treatment in either pathway.
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Affiliation(s)
- Alison Bradley
- Department of Management Science, Strathclyde Business School, University of Strathclyde, Glasgow, Scotland, United Kingdom
- West of Scotland Pancreatic Cancer Unit, Glasgow Royal Infirmary, Glasgow, Scotland, United Kingdom
- * E-mail:
| | - Robert Van Der Meer
- Department of Management Science, Strathclyde Business School, University of Strathclyde, Glasgow, Scotland, United Kingdom
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Dhir M, Malhotra GK, Sohal DP, Hein NA, Smith LM, O’Reilly EM, Bahary N, Are C. Neoadjuvant treatment of pancreatic adenocarcinoma: a systematic review and meta-analysis of 5520 patients. World J Surg Oncol 2017; 15:183. [PMID: 29017581 PMCID: PMC5634869 DOI: 10.1186/s12957-017-1240-2] [Citation(s) in RCA: 106] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Accepted: 08/25/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Recent years have seen standardization of the anatomic definitions of pancreatic adenocarcinoma, and increasing utilization of neoadjuvant therapy (NAT). The aim of the current review was to summarize the evidence for NAT in pancreatic adenocarcinoma since 2009, when consensus criteria for resectable (R), borderline resectable (BR), and locally advanced (LA) disease were endorsed. METHODS PubMed search was undertaken along with extensive backward search of the references of published articles to identify studies utilizing NAT for pancreatic adenocarcinoma. Abstracts from ASCO-GI 2014 and 2015 were also searched. RESULTS A total of 96 studies including 5520 patients were included in the final quantitative synthesis. Pooled estimates revealed 36% grade ≥ 3 toxicities, 5% biliary complications, 21% hospitalization rate and low mortality (0%, range 0-16%) during NAT. The majority of patients (59%) had stable disease. On an intention-to-treat basis, R0-resection rates varied from 63% among R patients to 23% among LA patients. R0 rates were > 80% among all patients who were resected after NAT. Among R and BR patients who underwent resection after NAT, median OS was 30 and 27.4 months, respectively. CONCLUSIONS The current study summarizes the recent literature for NAT in pancreatic adenocarcinoma and demonstrates improving outcomes after NAT compared to those historically associated with a surgery-first approach for pancreatic adenocarcinoma.
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Affiliation(s)
- Mashaal Dhir
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY 13210 USA
| | - Gautam K. Malhotra
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE 98198 USA
| | - Davendra P.S. Sohal
- Division of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44195 USA
| | - Nicholas A. Hein
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE 68198 USA
| | - Lynette M. Smith
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE 68198 USA
| | - Eileen M. O’Reilly
- David M. Rubenstein Center for Pancreatic Cancer, Memorial Sloan Kettering Cancer Center, New York, NY 10065 USA
| | - Nathan Bahary
- Department of Medicine, Division of Hematology and Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA 15232 USA
| | - Chandrakanth Are
- Department of Surgery, Division of Surgical Oncology, University of Nebraska Medical Center, Omaha, NE 98198 USA
- Department of Surgery/Genetics, Cell Biology and Anatomy, University of Nebraska Medical Center, Omaha, NE 68198 USA
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Desai NV, Sliesoraitis S, Hughes SJ, Trevino JG, Zlotecki RA, Ivey AM, George TJ. Multidisciplinary neoadjuvant management for potentially curable pancreatic cancer. Cancer Med 2015; 4:1224-39. [PMID: 25766842 PMCID: PMC4559034 DOI: 10.1002/cam4.444] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 02/12/2015] [Accepted: 02/14/2015] [Indexed: 12/24/2022] Open
Abstract
Pancreatic adenocarcinoma remains the fourth leading cause of cancer mortality in the U.S. Despite advances in surgical technique, radiotherapy technologies, and chemotherapeutics, the 5-year survival rate remains approximately 20% for the 15% of patients who are eligible for surgical resection. The majority of this group suffers metastatic recurrence. However, despite advances in therapies for patients with advanced pancreatic cancer, only surgery has consistently proven to improve long-term survival. Various combinations of chemotherapy, biologic-targeted therapy, and radiotherapy have been evaluated in different settings to improve outcomes. In this context, a neoadjuvant (preoperative) treatment strategy offers numerous potential benefits: (1) ensuring delivery of early, systemic therapy, (2) improving selection of patients for surgical therapy with truly localized disease, (3) potential downstaging of the neoplasm facilitating a negative margin resection in patients with locally advanced disease, and (4) providing a superior clinical trial mechanism capable of rapid assessment of the efficacy of novel therapeutics. This article reviews the recent trends in the management of pancreatic adenocarcinoma, with a particular emphasis on a multidisciplinary neoadjuvant approach to treatment.
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Affiliation(s)
- Neelam V Desai
- Division of Hematology and Oncology, Department of Medicine, University of Florida, Gainesville, Florida
| | - Sarunas Sliesoraitis
- Division of Hematology and Oncology, Department of Medicine, University of Florida, Gainesville, Florida
| | - Steven J Hughes
- Department of Surgery, University of Florida, Gainesville, Florida
| | - Jose G Trevino
- Department of Surgery, University of Florida, Gainesville, Florida
| | - Robert A Zlotecki
- Department of Radiation Oncology, University of Florida, Gainesville, Florida
| | - Alison M Ivey
- University of Florida Health Cancer Center, Gainesville, Florida
| | - Thomas J George
- Division of Hematology and Oncology, Department of Medicine, University of Florida, Gainesville, Florida
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Franke AJ, Rosati LM, Pawlik TM, Kumar R, Herman JM. The role of radiation therapy in pancreatic ductal adenocarcinoma in the neoadjuvant and adjuvant settings. Semin Oncol 2014; 42:144-62. [PMID: 25726059 DOI: 10.1053/j.seminoncol.2014.12.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pancreatic adenocarcinoma (PCA) is associated with high rates of cancer-related morbidity and mortality. Yet despite modern treatment advances, the only curative therapy remains surgical resection. The adjuvant therapeutic standard of care for PCA in the United States includes both chemotherapy and chemoradiation; however, an optimal regimen has not been established. For patients with resectable and borderline resectable PCA, recent investigation has focused efforts on evaluating the feasibility and efficacy of neoadjuvant therapy. Neoadjuvant therapy allows for early initiation of systemic therapy and identification of patients who harbor micrometastatic disease, thus sparing patients the potential morbidities associated with unnecessary radiation or surgery. This article critically reviews the data supporting or refuting the role of radiation therapy in the neoadjuvant and adjuvant settings of PCA management, with a particular focus on determining which patients may be more likely to benefit from radiation therapy.
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Affiliation(s)
- Aaron J Franke
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Lauren M Rosati
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Timothy M Pawlik
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rachit Kumar
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Joseph M Herman
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD.
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Kobayashi M, Mizuno S, Murata Y, Kishiwada M, Usui M, Sakurai H, Tabata M, Ii N, Yamakado K, Inoue H, Shiraishi T, Yamada T, Isaji S. Gemcitabine-based chemoradiotherapy followed by surgery for borderline resectable and locally unresectable pancreatic ductal adenocarcinoma: significance of the CA19-9 reduction rate and intratumoral human equilibrative nucleoside transporter 1 expression. Pancreas 2014; 43:350-60. [PMID: 24622063 PMCID: PMC4210173 DOI: 10.1097/mpa.0000000000000059] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2013] [Accepted: 09/22/2013] [Indexed: 12/16/2022]
Abstract
OBJECTIVES This study aimed to evaluate the efficacy of gemcitabine-based chemoradiotherapy followed by surgery (gem-CRTS) for pancreatic ductal adenocarcinoma (PDAC) for borderline resectable (BR) and locally unresectable (UR) tumors. METHODS One hundred patients with PDAC who underwent the gem-CRTS protocol were classified into 3 groups, namely, resectable (R; 14), BR (44), and UR (42). After chemoradiotherapy, the patients were reassessed for curative-intent resection. RESULTS At reassessment, distant metastases became apparent in 27% of R patients, in 12% of BR patients, and in 18% of UR patients. The multivariate analysis of preoperative factors indicated that the CA19-9 reduction rate was an independent prognostic factor in the BR group. Among reassessed patients, the resection rate was 63.6% in R, 83.7% in BR, and 50.0% in UR patients. In 63 patients that underwent curative-intent resection, the 3-year survival rate was 83.3% in R, 33.0% in BR, and 7.8% in UR patients. Using multivariate analysis, the independent prognostic factor was found to be the surgical margin in BR patients and human equilibrative nucleoside transporter 1 expression in UR patients. CONCLUSIONS We consider that our gem-CRTS protocol, even for locally UR PDAC, allows for the identification of candidates for aggressive resection at the time of reassessment and improved prognosis in the patients with positive human equilibrative nucleoside transporter 1 expression.
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Affiliation(s)
- Motoyuki Kobayashi
- From the Departments of *Hepatobiliary Pancreatic and Transplant Surgery, †Radiology, ‡Gastroenterology and Hepatology, and §Pathology, and ∥Translational Medical Science, Mie University School of Medicine, Mie, Japan
| | - Shugo Mizuno
- From the Departments of *Hepatobiliary Pancreatic and Transplant Surgery, †Radiology, ‡Gastroenterology and Hepatology, and §Pathology, and ∥Translational Medical Science, Mie University School of Medicine, Mie, Japan
| | - Yasuhiro Murata
- From the Departments of *Hepatobiliary Pancreatic and Transplant Surgery, †Radiology, ‡Gastroenterology and Hepatology, and §Pathology, and ∥Translational Medical Science, Mie University School of Medicine, Mie, Japan
| | - Masashi Kishiwada
- From the Departments of *Hepatobiliary Pancreatic and Transplant Surgery, †Radiology, ‡Gastroenterology and Hepatology, and §Pathology, and ∥Translational Medical Science, Mie University School of Medicine, Mie, Japan
| | - Masanobu Usui
- From the Departments of *Hepatobiliary Pancreatic and Transplant Surgery, †Radiology, ‡Gastroenterology and Hepatology, and §Pathology, and ∥Translational Medical Science, Mie University School of Medicine, Mie, Japan
| | - Hiroyuki Sakurai
- From the Departments of *Hepatobiliary Pancreatic and Transplant Surgery, †Radiology, ‡Gastroenterology and Hepatology, and §Pathology, and ∥Translational Medical Science, Mie University School of Medicine, Mie, Japan
| | - Masami Tabata
- From the Departments of *Hepatobiliary Pancreatic and Transplant Surgery, †Radiology, ‡Gastroenterology and Hepatology, and §Pathology, and ∥Translational Medical Science, Mie University School of Medicine, Mie, Japan
| | - Noriko Ii
- From the Departments of *Hepatobiliary Pancreatic and Transplant Surgery, †Radiology, ‡Gastroenterology and Hepatology, and §Pathology, and ∥Translational Medical Science, Mie University School of Medicine, Mie, Japan
| | - Koichiro Yamakado
- From the Departments of *Hepatobiliary Pancreatic and Transplant Surgery, †Radiology, ‡Gastroenterology and Hepatology, and §Pathology, and ∥Translational Medical Science, Mie University School of Medicine, Mie, Japan
| | - Hiroyuki Inoue
- From the Departments of *Hepatobiliary Pancreatic and Transplant Surgery, †Radiology, ‡Gastroenterology and Hepatology, and §Pathology, and ∥Translational Medical Science, Mie University School of Medicine, Mie, Japan
| | - Taizo Shiraishi
- From the Departments of *Hepatobiliary Pancreatic and Transplant Surgery, †Radiology, ‡Gastroenterology and Hepatology, and §Pathology, and ∥Translational Medical Science, Mie University School of Medicine, Mie, Japan
| | - Tomomi Yamada
- From the Departments of *Hepatobiliary Pancreatic and Transplant Surgery, †Radiology, ‡Gastroenterology and Hepatology, and §Pathology, and ∥Translational Medical Science, Mie University School of Medicine, Mie, Japan
| | - Shuji Isaji
- From the Departments of *Hepatobiliary Pancreatic and Transplant Surgery, †Radiology, ‡Gastroenterology and Hepatology, and §Pathology, and ∥Translational Medical Science, Mie University School of Medicine, Mie, Japan
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Ding X, Dionisi F, Tang S, Ingram M, Hung CY, Prionas E, Lichtenwalner P, Butterwick I, Zhai H, Yin L, Lin H, Kassaee A, Avery S. A comprehensive dosimetric study of pancreatic cancer treatment using three-dimensional conformal radiation therapy (3DCRT), intensity-modulated radiation therapy (IMRT), volumetric-modulated radiation therapy (VMAT), and passive-scattering and modulated-scanning proton therapy (PT). Med Dosim 2014; 39:139-45. [PMID: 24661778 DOI: 10.1016/j.meddos.2013.11.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 09/27/2013] [Accepted: 11/11/2013] [Indexed: 12/31/2022]
Abstract
With traditional photon therapy to treat large postoperative pancreatic target volume, it often leads to poor tolerance of the therapy delivered and may contribute to interrupted treatment course. This study was performed to evaluate the potential advantage of using passive-scattering (PS) and modulated-scanning (MS) proton therapy (PT) to reduce normal tissue exposure in postoperative pancreatic cancer treatment. A total of 11 patients with postoperative pancreatic cancer who had been previously treated with PS PT in University of Pennsylvania Roberts Proton Therapy Center from 2010 to 2013 were identified. The clinical target volume (CTV) includes the pancreatic tumor bed as well as the adjacent high-risk nodal areas. Internal (iCTV) was generated from 4-dimensional (4D) computed tomography (CT), taking into account target motion from breathing cycle. Three-field and 4-field 3D conformal radiation therapy (3DCRT), 5-field intensity-modulated radiation therapy, 2-arc volumetric-modulated radiation therapy, and 2-field PS and MS PT were created on the patients' average CT. All the plans delivered 50.4Gy to the planning target volume (PTV). Overall, 98% of PTV was covered by 95% of the prescription dose and 99% of iCTV received 98% prescription dose. The results show that all the proton plans offer significant lower doses to the left kidney (mean and V18Gy), stomach (mean and V20Gy), and cord (maximum dose) compared with all the photon plans, except 3-field 3DCRT in cord maximum dose. In addition, MS PT also provides lower doses to the right kidney (mean and V18Gy), liver (mean dose), total bowel (V20Gy and mean dose), and small bowel (V15Gy absolute volume ratio) compared with all the photon plans and PS PT. The dosimetric advantage of PT points to the possibility of treating tumor bed and comprehensive nodal areas while providing a more tolerable treatment course that could be used for dose escalation and combining with radiosensitizing chemotherapy.
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Affiliation(s)
- Xuanfeng Ding
- Perelman School of Medicine, Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Francesco Dionisi
- Perelman School of Medicine, Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Shikui Tang
- Perelman School of Medicine, Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Mark Ingram
- Perelman School of Medicine, Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Chun-Yu Hung
- Perelman School of Medicine, Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Evangelos Prionas
- Perelman School of Medicine, Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Phil Lichtenwalner
- Perelman School of Medicine, Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Ian Butterwick
- Perelman School of Medicine, Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Huifang Zhai
- Perelman School of Medicine, Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Lingshu Yin
- Perelman School of Medicine, Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Haibo Lin
- Perelman School of Medicine, Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Alireza Kassaee
- Perelman School of Medicine, Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Stephen Avery
- Perelman School of Medicine, Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA.
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Valesin Filho ES, de Abreu LC, Lima GHV, de Cubero DIG, Ueno FH, Figueiredo GSL, Valenti VE, Monteiro CBDM, Wajnsztejn R, Fujiki EN, Neto MR, Rodrigues LM. Pain and quality of life in patients undergoing radiotherapy for spinal metastatic disease treatment. Int Arch Med 2013; 6:6. [PMID: 23418821 PMCID: PMC3599966 DOI: 10.1186/1755-7682-6-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Accepted: 02/08/2013] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Radiotherapy is an important tool in the control of pain in patients with spinal metastatic disease. We aimed to evaluate pain and of quality of life of patients with spinal metastatic disease undergoing radiotherapy with supportive treatment. METHODS The study enrolled 30 patients. From January 2008 to January 2010, patients selection included those treated with a 20 Gy tumour dose in five fractions. Patients completed the visual analogue scale for pain assessment and the SF-36 questionnaire for quality of life assessment. RESULTS The most frequent primary sites were breast, multiple myeloma, prostate and lymphoma. It was found that 14 spinal metastatic disease patients (46.66%) had restricted involvement of three or fewer vertebrae, while 16 patients (53.33%) had cases involving more than three vertebrae. The data from the visual analogue scale evaluation of pain showed that the average initial score was 5.7 points, the value 30 days after the end of radiotherapy was 4.60 points and the average value 6 months after treatment was 4.25 points. Notably, this final value was 25.43% lower than the value from the initial analysis. With regard to the quality of life evaluation, only the values for the functional capability and social aspects categories of the questionnaire showed significant improvement. CONCLUSION Radiotherapy with supportive treatment appears to be an important tool for the treatment of pain in patients with spinal metastatic disease.
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Affiliation(s)
| | - Luiz Carlos de Abreu
- Laboratório de Delineamento de Estudos e Escrita Científica. Departamento de Morfologia e Fisiologia, Faculdade de Medicina do ABC, Av. Príncipe de Gales, 821, 09060-650, Santo André, SP, Brazil
| | | | | | | | | | - Vitor E Valenti
- Laboratório de Delineamento de Estudos e Escrita Científica. Departamento de Morfologia e Fisiologia, Faculdade de Medicina do ABC, Av. Príncipe de Gales, 821, 09060-650, Santo André, SP, Brazil
- Faculdade de Filosofia e Ciências, Universidade Estadual Paulista, UNESP. Av. Hygino Muzzi Filho, 737, 17.525-900, Marília, SP, Brazil
| | - Carlos Bandeira de Mello Monteiro
- Laboratório de Delineamento de Estudos e Escrita Científica. Departamento de Morfologia e Fisiologia, Faculdade de Medicina do ABC, Av. Príncipe de Gales, 821, 09060-650, Santo André, SP, Brazil
- Escola de Artes, Ciências e Humanidades da Universidade de São Paulo, São Paulo, Brazil
| | - Rubens Wajnsztejn
- Laboratório de Delineamento de Estudos e Escrita Científica. Departamento de Morfologia e Fisiologia, Faculdade de Medicina do ABC, Av. Príncipe de Gales, 821, 09060-650, Santo André, SP, Brazil
| | - Edison N Fujiki
- Hospital Estadual Mário Covas, Santo André, SP, Brazil
- Laboratório de Delineamento de Estudos e Escrita Científica. Departamento de Morfologia e Fisiologia, Faculdade de Medicina do ABC, Av. Príncipe de Gales, 821, 09060-650, Santo André, SP, Brazil
| | - Modesto Rolim Neto
- Laboratório de Delineamento de Estudos e Escrita Científica. Departamento de Morfologia e Fisiologia, Faculdade de Medicina do ABC, Av. Príncipe de Gales, 821, 09060-650, Santo André, SP, Brazil
| | - Luciano M Rodrigues
- Hospital Estadual Mário Covas, Santo André, SP, Brazil
- Laboratório de Delineamento de Estudos e Escrita Científica. Departamento de Morfologia e Fisiologia, Faculdade de Medicina do ABC, Av. Príncipe de Gales, 821, 09060-650, Santo André, SP, Brazil
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Ductal carcinoma in situ in core needle biopsies and its association with extensive in situ component in the surgical specimen. Int Arch Med 2012; 5:19. [PMID: 22715888 PMCID: PMC3432016 DOI: 10.1186/1755-7682-5-19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Accepted: 05/16/2012] [Indexed: 11/30/2022] Open
Abstract
Background We evaluated the presence of ductal carcinoma in situ (DCIS) in core needle biopsies (CNB) from invasive ductal lesions. Methods Retrospective study, which analyzed 90 cases of invasive ductal carcinoma lesions. The percentage of DCIS was quantified in each specimens obtained from CNB, which were compared to the surgical specimens. CNB and surgical specimens were evaluated by the same pathologist, and the percentage of DCIS in CNB was evaluated (percentage) and divided into categories. We considered the following parameters regarding the amount of DCIS: 1 = 0; 2 = 1 for 5%; 3 = 6 for 24%; 4 = 25 for 50%; 5 = 51 for 75% and 6 = 76 for 99%. The number of fragments and the histological pattern of DCIS was found. Results We found the following results regarding the distribution of the percentage of DCIS in the CNB: 1 = 63.3%; 2 = 12.2%; 3 = 12.2%; 4 = 5.6%; 5 = 1.1% and 6 = 5.6%. The logistic regression analysis showed that CNB percentages above 45% reflected the presence of DCIS in the surgical specimen in 100% of the cases (p < 0.001), with a specificity of 100%, accuracy of 83.3% and false positive rate of 0% (p <0.001). Conclusion There is direct relationship between extensive intraductal component in the surgical specimen when the core biopsy shows 45% or more of the DCI or microinvasive in the material examined.
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10
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Andriulli A, Festa V, Botteri E, Valvano MR, Koch M, Bassi C, Maisonneuve P, Sebastiano PD. Neoadjuvant/preoperative gemcitabine for patients with localized pancreatic cancer: a meta-analysis of prospective studies. Ann Surg Oncol 2011; 19:1644-62. [PMID: 22012027 DOI: 10.1245/s10434-011-2110-8] [Citation(s) in RCA: 131] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Indexed: 12/21/2022]
Abstract
BACKGROUND Long-term prognosis for localized pancreatic cancer remains poor. We sought to assess the benefit of neoadjuvant/preoperative chemotherapy with or without radiotherapy. METHODS Prospective studies where gemcitabine with or without radiotherapy was provided before surgery in patients with initially resectable or unresectable disease were reviewed by meta-analysis. Primary outcome was survival, and secondary outcomes were tumor response after therapy, toxicity, surgical exploration, and resection rates. RESULTS Twenty independent studies with 707 participants were included, 366 with resectable lesions and 341 with unresectable lesions. Seven studies were phase I/II trials, 10 phase II, and 3 prospective cohort studies. Estimated 1- and 2-year survival probabilities after resection were 91.7% (95% confidence interval [CI] 75-100) and 67.2% (95% CI 38-87) for initially resectable patients, and 86.3% (95% CI 78-100) and 54.2% (95% CI 25-100) for initially unresectable patients. The complete/partial response rate was 12% (95% CI 4-23) and 27% (95% CI 18-38) in resectable and unresectable lesions, respectively. The rate of treatment-related grade 3-4 toxicity was 31% (95% CI 21-42). Of resectable patients evaluable after restaging, 91% (95% CI 83-97) underwent surgery, and 82% (95% CI 65-95) of explored patients underwent resection. R0 resections amounted to 89% (95% CI 83-94). Of unresectable patients evaluable after restaging, 39% (95% CI 28-50) underwent surgery, and 68% (95% CI 53-82) of explored patients were resected, with 60% (95% CI 50-71) R0 resections. CONCLUSIONS Current analysis provides marginal support to the assumed benefits of neoadjuvant therapies for patients with resectable cancer, and indicates a potential advantage only for a minority of those with unresectable lesions.
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Affiliation(s)
- Angelo Andriulli
- Division of Gastroenterology, "Casa Sollievo della Sofferenza" Hospital, IRCCS, San Giovanni Rotondo, Italy
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Mamon HJ, Niedzwiecki D, Hollis D, Tan BR, Mayer RJ, Tepper JE, Goldberg RM, Blackstock AW, Fuchs CS. A phase 2 trial of gemcitabine, 5-fluorouracil, and radiation therapy in locally advanced nonmetastatic pancreatic adenocarcinoma : cancer and Leukemia Group B (CALGB) 80003. Cancer 2011; 117:2620-8. [PMID: 21656739 PMCID: PMC3116970 DOI: 10.1002/cncr.25742] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2010] [Revised: 08/11/2010] [Accepted: 09/08/2010] [Indexed: 01/18/2023]
Abstract
BACKGROUND The purpose of this study was to assess the efficacy and safety of 5-fluorouracil (5FU) and gemcitabine administered concurrently with radiation in patients with locally advanced, nonmetastatic pancreatic cancer. METHODS Eligible patients had histologically confirmed pancreatic adenocarcinoma deemed locally unresectable without evidence of metastatic disease. In addition, all patients underwent laparoscopy or laparotomy before study entry to rule out peritoneal carcinomatosis. Patients received radiation therapy (50.4 Gy) with concurrent infusional 5FU (200 mg/m(2) 5 days/week) and weekly gemcitabine (200 mg/m(2) ). After a 3-week break, patients received weekly gemcitabine at 1000 mg/m(2) for 3 of 4 weeks, for 4 cycles. The primary endpoint of the trial was the proportion of patients surviving 9 months from study entry. Secondary endpoints included objective tumor response, CA19-9 response, overall survival (OS) time to progression (TTP), and toxicity. RESULTS Between November 2001 and October 2004, 81 patients were enrolled, 78 of whom were eligible for analysis. With a median follow-up of 55.2 months, the median OS was 12.2 months (95% confidence interval [CI], 10.9-14.9) and the median TTP was 10 months (95% CI, 6.4-12.0). An objective tumor response was seen in 19 patients (25%), and among 56 patients with an elevated CA19-9 at baseline, 29 (52%) had a sustained CA19-9 response. Overall, 41% of patients had grade 3 or greater treatment-related gastrointestinal adverse events. CONCLUSIONS The combination of 5FU, gemcitabine, and radiation is well tolerated. Survival is comparable with the best results of other recent studies of 5FU and radiation or gemcitabine and radiation.
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Affiliation(s)
- Harvey J Mamon
- Dana Farber Cancer Institute, Boston, Massachusetts; Brigham and Women's Hospital, Boston, MA 02115, USA.
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Kyriazanos ID, Tsoukalos GG, Papageorgiou G, Verigos KE, Miliadis L, Stoidis CN. Local recurrence of pancreatic cancer after primary surgical intervention: how to deal with this devastating scenario? Surg Oncol 2011; 20:e133-42. [PMID: 21576013 DOI: 10.1016/j.suronc.2011.04.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Revised: 04/13/2011] [Accepted: 04/18/2011] [Indexed: 02/08/2023]
Abstract
The dismal prognosis of pancreatic cancer reflects into the increased recurrence rate, even after R0 pancreaticoduodenectomy. Although, conventional radiation-, chemo- or surgical therapy in much selected cases, seem to work out favorably long term, less invasive and non-toxic methods with more immediate results are always preferred, concerning the already aggravated status of this group of patients. We present hereby a comprehensive review of the literature concerning the treatment of recurrent pancreatic cancer based on the case of a patient who 20 months after a pancreaticoduodenectomy developed portal hypertension and symptomatic first degree esophageal, gastric and mesenteric varices, caused by the nearly complete splenic vein obstruction at the portal vein confluence. The varices were revascularized by a percutaneous transhepatic placement of an endovascular stent into the splenic vein, along with a sequent stereotactic body radiation therapy for the local tumor control. Thanks to the accuracy and safety of the present combined treatment, the patient one year later presents control of the disease and its complications. Our paper is the first in the international literature that tries to review all the treatment modalities available (surgical, adjuvant, neoadjuvant and palliative therapy) and their efficacy, concerning the locally recurrent pancreatic cancer; furthermore, we tried to analyze the application of the above mentioned combined therapeutic approach in similar cases, elucidating simultaneously all the questions that arise. The limited existing data in the international literature and the lack of randomized controlled trials make this effort difficult, but the physician should be aware after all of all the available and innovative treatment modalities, before he chooses one. Finally, we would like to emphasize the fact that not only the local control but also the management of the complications are important for a prolonged median survival and a better quality of life after all.
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Affiliation(s)
- Ioannis D Kyriazanos
- Department of Surgery, Athens Navy Hospital, 70 Deinokratous str., 11521 Athens, Greece.
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Ferreira M, Valenti VE, Cisternas JR, Ferreira C, Meneghini A, Filho CF, Breda JR, Correa JA, de Mello Monteiro CB, Junior HM, Murad N, de Abreu LC. Memantine effects on liver and adrenal gland of rats exposed to cold stress. Int Arch Med 2011; 4:5. [PMID: 21255456 PMCID: PMC3033327 DOI: 10.1186/1755-7682-4-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2010] [Accepted: 01/22/2011] [Indexed: 01/09/2023] Open
Abstract
Background Memantine attenuates heart stress due cold stress, however, no study focused its effects on liver and adrenal gland. We evaluated its effects on lipid depletion in adrenal gland and glycogen depletion in liver of rats exposed to cold stress. Methods Male rats divided into 4 groups: 1)Control (CON); 2)Memantine (MEM); 3)Induced cold stress (IH) and; 4)Induced cold stress memantine (IHF). Memantine were administrated by gavage (20 mg/kg/day) during eight days. Cold stress were performed during 4 hours once at - 8°C. Lipid and glycogen depletion were presented as its intensity levels. Results Rats exposed to cold stress presented the highest glycogen (p < 0.001) and lipid depletion (p < 0.001) in liver and adrenal gland, respectively. We noted that memantine significantly reduced lipid depletion in adrenal gland and glycogen depletion in liver. Conclusion Memantine prevented glycogen depletion in liver and lipid depletion in adrenal gland of rats under a cold stress condition.
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Affiliation(s)
- Marcelo Ferreira
- Laboratório de Escrita Científica, Departamento de Morfologia e Fisiologia, Faculdade de Medicina do ABC, Santo André, SP, Brasil.
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Chemoradiation for Unresectable Gall Bladder Cancer: Time to Review Historic Nihilism? J Gastrointest Cancer 2010; 42:222-7. [DOI: 10.1007/s12029-010-9179-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Polistina F, Costantin G, Casamassima F, Francescon P, Guglielmi R, Panizzoni G, Febbraro A, Ambrosino G. Unresectable locally advanced pancreatic cancer: a multimodal treatment using neoadjuvant chemoradiotherapy (gemcitabine plus stereotactic radiosurgery) and subsequent surgical exploration. Ann Surg Oncol 2010; 17:2092-101. [PMID: 20224860 DOI: 10.1245/s10434-010-1019-y] [Citation(s) in RCA: 139] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2009] [Indexed: 12/17/2022]
Abstract
BACKGROUND Pancreatic cancer accounts for approximately 3% of cancer deaths in Europe. Locally advanced pancreatic cancer (LAPC) involves vascular structures, and resectability is low, with a median survival time of 6 to 11 months. We conducted a prospective, nonrandomized study of patients with LAPC to assess the effect of stereotactic body radiotherapy (SBRT) on local response, pain control, and quality of life (QOL). METHODS Twenty-three patients with histologically confirmed LAPC underwent SBRT. Radiotherapy (30 Gy) was delivered in three fractions, and treatment toxicity was assessed according to the Common Terminology Criteria for Adverse Events (CTCAE v. 3.0). All patients received also gemcitabine chemotherapy and were followed up until death. Local control was assessed according to Response Evaluation Criteria in Solid Tumors (RECIST) criteria, pain control was assessed with a visual analog scale, and QOL was assessed with the SF-36 instrument (Italian v. 1.6). RESULTS No grade 2 or higher acute or late toxicity was observed. The overall local response ratio was 82.6% (14 partial response, 2 complete response, 3 stable disease). SBRT showed a good short-term efficacy in controlling both pain and QOL. Median survival was 10.6 months, with a median follow-up of 9 months. The LAPC became resectable in 8% of the patients. Median time to progression of disease was 7.3 months. Six patients developed early metastatic disease. CONCLUSIONS The SBRT method is a promising treatment for LAPC. Local control rates, even compared to historical data from conventional radiotherapy, can be achieved with minimal toxicity. Resectability can also be achieved.
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