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Elshami M, Wu VS, Stitzel HJ, Hue JJ, Loftus AW, Kyasaram RK, Shanahan J, Ammori JB, Hardacre JM, Ocuin LM. To Revise or Not Revise? Isolated Margin Positivity in Localized Pancreatic Ductal Adenocarcinoma. Ann Surg Oncol 2024; 31:6170-6179. [PMID: 38896228 PMCID: PMC11300499 DOI: 10.1245/s10434-024-15616-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: 04/04/2024] [Accepted: 05/26/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND The study determined the proportion of patients with pancreatic adenocarcinoma (PDAC) who had margin-positive disease and no other adverse pathologic findings (APF) using institutional and administrative datasets. METHODS Patients with clinical stage I or II PDAC in the National Cancer Database (NCDB 2010-2020) and those who underwent pancreatectomy at the authors' institution (2010-2021) were identified. Isolated margin positivity (IMP) was defined as a positive surgical margin with no APF (negative nodes, no lymphovascular/perineural invasion). RESULTS The study included 225 patients from the authors' institution and 23,598 patients from the NCDB. The margin-positive rates were 21.8% and 20.3%, and the IMP rates were 0.4% and 0.5%, respectively. In the institutional cohort, 68.4% of the patients had recurrence, and most of the patients (65.6%) had distant recurrences. The median recurrence-free survival (RFS) was 63.3 months for no APF, not reached for IMP, 14.8 months for negative margins & 1 APF, 20.3 months for positive margins & 2 APFs, and 12.9 months with all APF positive. The patients in the NCDB with IMP had a lower median OS than the patients with no APF (20.5 vs 390 months), but a higher median OS than those with margin positivity plus 1 APF (20.5 vs 18.0 months) or all those with APF positivity (20.5 vs 15.4 months). Based on institutional rates of IMP, any margin positivity, neck margin positivity (NMP), and no APF, the fraction of patients who might benefit from neck margin revision was 1 in 100,000, and those likely to benefit from any margin revision was 1 in 18,500. In the NCDB, those estimated to derive potential benefit from margin revision was 1 in 25,000. CONCLUSIONS Isolated margin positivity in resected PDAC is rare, and most patients experience distant recurrence. Revision of IMP appears unlikely to confer benefit to most patients.
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Affiliation(s)
- Mohamedraed Elshami
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Victoria S Wu
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Henry J Stitzel
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Jonathan J Hue
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Alexander W Loftus
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Ravi K Kyasaram
- Department of Cancer Informatics, University Hospitals Cleveland Medical Center/Seidman Cancer Center, Cleveland, OH, USA
| | - John Shanahan
- Department of Cancer Informatics, University Hospitals Cleveland Medical Center/Seidman Cancer Center, Cleveland, OH, USA
| | - John B Ammori
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jeffrey M Hardacre
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Lee M Ocuin
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
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2
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Lorestani P, Dashti M, Nejati N, Habibi MA, Askari M, Robat-Jazi B, Ahmadpour S, Tavakolpour S. The complex role of macrophages in pancreatic cancer tumor microenvironment: a review on cancer progression and potential therapeutic targets. Discov Oncol 2024; 15:369. [PMID: 39186144 PMCID: PMC11347554 DOI: 10.1007/s12672-024-01256-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Accepted: 08/20/2024] [Indexed: 08/27/2024] Open
Abstract
Pancreatic cancer (PC) is one of the deadliest cancers worldwide with low survival rates and poor outcomes. The treatment landscape for PC is fraught with obstacles, including drug resistance, lack of effective targeted therapies and the immunosuppressive tumor microenvironment (TME). The resistance of PC to existing immunotherapies highlights the need for innovative approaches, with the TME emerging as a promising therapeutic target. The recent advancements in understanding the role of macrophages, this context highlight their significant impact on tumor development and progression. There are two important types of macrophages: M1 and M2, which play critical roles in the TME. Therapeutics strategies including, depletion of tumor-associated macrophages (TAMs), reprogramming TAMs to promote anti-tumor activity, and targeting macrophage recruitment can lead to promising outcomes. Targeting macrophage-related pathways may offer novel strategies for modulating immune responses, inhibiting angiogenesis, and overcoming resistance to chemotherapy in PC treatment.
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Affiliation(s)
- Parsa Lorestani
- Students Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mohsen Dashti
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Negar Nejati
- Pediatric Cell and Gene Therapy Research Centre, Gene, Cell & Tissue Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Amin Habibi
- Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mandana Askari
- Department of Nanobiotechnology, Faculty of Biological Sciences, Tarbiat Modares University, Tehran, Iran
| | - Behruz Robat-Jazi
- Department of Immunology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Sajjad Ahmadpour
- Patient Safety Research Center, Clinical Research Institute, Urmia University of Medical Sciences, Urmia, Iran.
| | - Soheil Tavakolpour
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, 02215, USA.
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3
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Stoop TF, Theijse RT, Seelen LWF, Groot Koerkamp B, van Eijck CHJ, Wolfgang CL, van Tienhoven G, van Santvoort HC, Molenaar IQ, Wilmink JW, Del Chiaro M, Katz MHG, Hackert T, Besselink MG. Preoperative chemotherapy, radiotherapy and surgical decision-making in patients with borderline resectable and locally advanced pancreatic cancer. Nat Rev Gastroenterol Hepatol 2024; 21:101-124. [PMID: 38036745 DOI: 10.1038/s41575-023-00856-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2023] [Indexed: 12/02/2023]
Abstract
Surgical resection combined with systemic chemotherapy is the cornerstone of treatment for patients with localized pancreatic cancer. Upfront surgery is considered suboptimal in cases with extensive vascular involvement, which can be classified as either borderline resectable pancreatic cancer or locally advanced pancreatic cancer. In these patients, FOLFIRINOX or gemcitabine plus nab-paclitaxel chemotherapy is currently used as preoperative chemotherapy and is eventually combined with radiotherapy. Thus, more patients might reach 5-year overall survival. Patient selection for chemotherapy, radiotherapy and subsequent surgery is based on anatomical, biological and conditional parameters. Current guidelines and clinical practices vary considerably regarding preoperative chemotherapy and radiotherapy, response evaluation, and indications for surgery. In this Review, we provide an overview of the clinical evidence regarding disease staging, preoperative therapy, response evaluation and surgery in patients with borderline resectable pancreatic cancer or locally advanced pancreatic cancer. In addition, a clinical work-up is proposed based on the available evidence and guidelines. We identify knowledge gaps and outline a proposed research agenda.
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Affiliation(s)
- Thomas F Stoop
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, Netherlands
- Cancer Center Amsterdam, Amsterdam, Netherlands
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Rutger T Theijse
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, Netherlands
- Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Leonard W F Seelen
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus Medical Center, Rotterdam, Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus Medical Center, Rotterdam, Netherlands
| | - Christopher L Wolfgang
- Division of Surgical Oncology, Department of Surgery, New York University Medical Center, New York City, NY, USA
| | - Geertjan van Tienhoven
- Cancer Center Amsterdam, Amsterdam, Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Radiation Oncology, Amsterdam, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, Netherlands
| | - Johanna W Wilmink
- Cancer Center Amsterdam, Amsterdam, Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Medical Oncology, Amsterdam, Netherlands
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Marc G Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, Netherlands.
- Cancer Center Amsterdam, Amsterdam, Netherlands.
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4
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de Jesus VHF, Peixoto RD, Ribeiro HSDC, Pinheiro RN, Oliveira AF, Anghinoni M, Torres SM, Boff MF, Weschenfelder R, Prolla G, Riechelmann RP. Current clinical practice in the management of Brazilian patients with potentially resectable pancreatic ductal adenocarcinoma (PDAC). J Surg Oncol 2023. [PMID: 37795658 DOI: 10.1002/jso.27453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 09/11/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND AND OBJECTIVES We aimed to describe the routine clinical practice of physicians involved in the treatment of patients with localized pancreatic ductal adenocarcinoma (PDAC) in Brazil. METHODS Physicians were invited through email and text messages to participate in an electronic survey sponsored by the Brazilian Gastrointestinal Tumor Group (GTG) and the Brazilian Society of Surgical Oncology (SBCO). We evaluated the relationship between variable categories numerically with false discovery rate-adjusted Fisher's exact test p values and graphically with Multiple Correspondence Analysis. RESULTS Overall, 255 physicians answered the survey. Most (52.5%) were medical oncologists, treated patients predominantly in the private setting (71.0%), and had access to multidisciplinary tumor boards (MTDTB; 76.1%). Medical oncologists were more likely to describe neoadjuvant therapy as beneficial in the resectable setting and surgeons in the borderline resectable setting. Most physicians would use information on risk factors for early recurrence, frailty, and type of surgery to decide treatment strategy. Doctors working predominantly in public institutions were less likely to have access to MTDTB and to consider FOLFIRINOX the most adequate regimen in the neoadjuvant setting. CONCLUSIONS Considerable differences exist in the management of localized PDAC, some of them possibly explained by the medical specialty, but also by the funding source of health care.
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Affiliation(s)
- Victor Hugo Fonseca de Jesus
- Medical Oncology Unit, Grupo Oncolínicas Florianópolis, Florianópolis, Santa Catarina, Brazil
- Medical Oncology Department, Centro de Pesquisas Oncológicas (CEPON), Florianópolis, Santa Catarina, Brazil
- Post-Graduate Program, A.C. Camargo Cancer, São Paulo, Sao Paulo, Brazil
| | - Renata D'Alpino Peixoto
- Medical Oncology Unit, Grupo Oncoclínicas/Centro Paulista de Oncologia, São Paulo, São Paulo, Brazil
| | | | | | | | - Marciano Anghinoni
- Surgical Oncology Unit, Centro de Oncologia do Paraná (Oncoville), Curitiba, Paraná, Brazil
| | - Silvio Melo Torres
- Department of Abdominal Surgery, A.C. Camargo Cancer, São Paulo, São Paulo, Brazil
| | - Márcio Fernando Boff
- Surgical Oncology Unit, Hospital Mãe de Deus, Porto Alegre, Rio Grande do Sul, Brazil
| | - Rui Weschenfelder
- Department of Medical Oncology, Hospital Moinho de Vento, Porto Alegre, Rio Grande do Sul, Brazil
| | - Gabriel Prolla
- Grupo Oncoclínicas Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Rachel P Riechelmann
- Department of Medical Oncology, A.C. Camargo Cancer, São Paulo, São Paulo, Brazil
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5
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Oba A, Del Chiaro M, Fujii T, Okano K, Stoop TF, Wu YHA, Maekawa A, Yoshida Y, Hashimoto D, Sugawara T, Inoue Y, Tanabe M, Sho M, Sasaki T, Takahashi Y, Matsumoto I, Sasahira N, Nagakawa Y, Satoi S, Schulick RD, Yoon YS, He J, Jang JY, Wolfgang CL, Hackert T, Besselink MG, Takaori K, Takeyama Y. "Conversion surgery" for locally advanced pancreatic cancer: A position paper by the study group at the joint meeting of the International Association of Pancreatology (IAP) & Japan Pancreas Society (JPS) 2022. Pancreatology 2023; 23:712-720. [PMID: 37336669 DOI: 10.1016/j.pan.2023.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 04/10/2023] [Accepted: 06/06/2023] [Indexed: 06/21/2023]
Abstract
Locally advanced pancreatic cancer (LAPC), which progresses locally and surrounds major vessels, has historically been deemed unresectable. Surgery alone failed to provide curative resection and improve overall survival. With the advancements in treatment, reports have shown favorable results in LAPC after undergoing successful chemotherapy therapy or chemoradiation therapy followed by surgical resection, so-called "conversion surgery", at experienced high-volume centers. However, recognizing significant regional and institutional disparities in the management of LAPC, an international consensus meeting on conversion surgery for LAPC was held during the Joint Congress of the 26th Meeting of the International Association of Pancreatology (IAP) and the 53rd Annual Meeting of Japan Pancreas Society (JPS) in Kyoto in July 2022. During the meeting, presenters reported the current best multidisciplinary practices for LAPC, including preoperative modalities, best systemic treatment regimens and durations, procedures of conversion surgery with or without vascular resections, biomarkers, and genetic studies. It was unanimously agreed among the experts in this meeting that "cancer biology is surpassing locoregional anatomical resectability" in the era of effective multiagent treatment. The biology of pancreatic cancer has yet to be further elucidated, and we believe it is essential to improve the treatment outcomes of LAPC patients through continued efforts from each institution and more international collaboration. This article summarizes the agreement during the discussion amongst the experts in the meeting. We hope that this will serve as a foundation for future international collaboration and recommendations for future guidelines.
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Affiliation(s)
- Atsushi Oba
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan; Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA; Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA.
| | - Tsutomu Fujii
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, Japan
| | - Keiichi Okano
- Department of Gastroenterological Surgery, Kagawa University School of Medicine, Kagawa, Japan
| | - Thomas F Stoop
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Y H Andrew Wu
- Department Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aya Maekawa
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan; Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yuta Yoshida
- Department of Surgery, Kindai University, Osaka, Japan
| | | | - Toshitaka Sugawara
- Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA; Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yosuke Inoue
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Minoru Tanabe
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Takashi Sasaki
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Yu Takahashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | | | - Naoki Sasahira
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Sohei Satoi
- Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA; Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Richard D Schulick
- Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jin He
- Department Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | | | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany; Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Germany
| | - Marc G Besselink
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
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6
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Wang W, Wang S, Huang X, Meng H, Jiang Y, Li B, Chen K, Shen B, Lin X. The value of 18F-fluorodeoxyglucose positron emission tomography/magnetic resonance whole-body scans and local enhancement scans in the preoperative staging and resectability assessment of pancreatic adenocarcinoma. Quant Imaging Med Surg 2023; 13:1768-1778. [PMID: 36915309 PMCID: PMC10006117 DOI: 10.21037/qims-22-731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 12/18/2022] [Indexed: 02/05/2023]
Abstract
Background In addition to contrast-enhanced multiphase computed tomography (CT) and magnetic resonance imaging (MRI), integrated positron emission tomography (PET)/magnetic resonance (MR) is increasingly being used for the preoperative evaluation of pancreatic cancer. The purpose of this study was to explore the value of hybrid 18F-fluorodeoxyglucose (18F-FDG) PET/MR imaging in preoperative assessment and treatment decision-making. Methods A retrospective data collection (of imaging, clinical, and pathological information) was conducted on patients who underwent 18F-FDG PET/MR with clinically diagnosed or suspected pancreatic cancer from March 2018 to March 2022 in Ruijin Hospital. The data of 76 patients were initially included, with 1 of the 76 patients eventually being excluded due to a misdiagnosis of inflammatory disease. Of the 75 patients, 38 underwent pancreatic tumor resection and 10 underwent laparoscopic exploration. The accuracy of 18F-FDG PET/MR for pancreatic cancer staging and the assessment of pancreatic resectability was evaluated based on pathological results, intraoperative findings, and documented final clinical stages of illness. The adjustments to patient treatment plans were also analyzed before and after 18F-FDG PET/MR examination. Results The accuracy of clinical tumor node metastasis (TNM) staging of pancreatic cancer by 18F-FDG PET/MR was 73.3% (55/75). The area under the curve (AUC) of 18F-FDG PET/MR for diagnosing the advanced stage (III-IV) versus the nonadvanced stage (I-II) of disease was 0.922 [95% confidence interval (CI): 0.852-0.993]. The treatment regimen of 20.0% (15/75) of patients was impacted. The accuracy of the evaluation of the resectability of pancreatic cancer with 18F-FDG PET/MR was 91.9% (34/37). With the surgical and pathological results being used as a reference, the overall accuracy of preoperative 18F-FDG PET/MR for T staging was 62.2%, and the AUC for diagnosing T4 versus T1-3 was 0.872 (95% CI: 0.660-1.000). Conclusions 18F-FDG PET/MR performs well in diagnosing advanced pancreatic cancer and thus may impact the treatment decisions for a considerable number of patients. 18F-FDG PET/MR has a high level of accuracy in evaluating the resectability of pancreatic cancer before surgery.
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Affiliation(s)
- Weishen Wang
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Research Institute of Pancreatic Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- State Key Laboratory of Oncogenes and Related Genes, Shanghai, China
- Institute of Translational Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Siwen Wang
- Department of Nuclear Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xinyun Huang
- Department of Nuclear Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hongping Meng
- Department of Nuclear Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yu Jiang
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Research Institute of Pancreatic Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- State Key Laboratory of Oncogenes and Related Genes, Shanghai, China
- Institute of Translational Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Biao Li
- Department of Nuclear Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Kemin Chen
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Baiyong Shen
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Research Institute of Pancreatic Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- State Key Laboratory of Oncogenes and Related Genes, Shanghai, China
- Institute of Translational Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaozhu Lin
- Department of Nuclear Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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7
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Firpo MA, Boucher KM, Bleicher J, Khanderao GD, Rosati A, Poruk KE, Kamal S, Marzullo L, De Marco M, Falco A, Genovese A, Adler JM, De Laurenzi V, Adler DG, Affolter KE, Garrido-Laguna I, Scaife CL, Turco MC, Mulvihill SJ. Multianalyte Serum Biomarker Panel for Early Detection of Pancreatic Adenocarcinoma. JCO Clin Cancer Inform 2023; 7:e2200160. [PMID: 36913644 PMCID: PMC10530881 DOI: 10.1200/cci.22.00160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 01/10/2023] [Accepted: 02/03/2023] [Indexed: 03/14/2023] Open
Abstract
PURPOSE We determined whether a large, multianalyte panel of circulating biomarkers can improve detection of early-stage pancreatic ductal adenocarcinoma (PDAC). MATERIALS AND METHODS We defined a biologically relevant subspace of blood analytes on the basis of previous identification in premalignant lesions or early-stage PDAC and evaluated each in pilot studies. The 31 analytes that met minimum diagnostic accuracy were measured in serum of 837 subjects (461 healthy, 194 benign pancreatic disease, and 182 early-stage PDAC). We used machine learning to develop classification algorithms using the relationship between subjects on the basis of their changes across the predictors. Model performance was subsequently evaluated in an independent validation data set from 186 additional subjects. RESULTS A classification model was trained on 669 subjects (358 healthy, 159 benign, and 152 early-stage PDAC). Model evaluation on a hold-out test set of 168 subjects (103 healthy, 35 benign, and 30 early-stage PDAC) yielded an area under the receiver operating characteristic curve (AUC) of 0.920 for classification of PDAC from non-PDAC (benign and healthy controls) and an AUC of 0.944 for PDAC versus healthy controls. The algorithm was then validated in 146 subsequent cases presenting with pancreatic disease (73 benign pancreatic disease and 73 early- and late-stage PDAC cases) and 40 healthy control subjects. The validation set yielded an AUC of 0.919 for classification of PDAC from non-PDAC and an AUC of 0.925 for PDAC versus healthy controls. CONCLUSION Individually weak serum biomarkers can be combined into a strong classification algorithm to develop a blood test to identify patients who may benefit from further testing.
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Affiliation(s)
- Matthew A. Firpo
- Department of Surgery, School of Medicine, University of Utah, Salt Lake City, UT
| | - Kenneth M. Boucher
- Department of Oncological Sciences, School of Medicine, University of Utah, Salt Lake City, UT
| | - Josh Bleicher
- Department of Surgery, School of Medicine, University of Utah, Salt Lake City, UT
| | - Gayatri D. Khanderao
- Department of Surgery, School of Medicine, University of Utah, Salt Lake City, UT
| | - Alessandra Rosati
- BIOUNIVERSA s.r.l., Baronissi, Italy
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana” University of Salerno, Baronissi, Italy
| | - Katherine E. Poruk
- Department of Surgery, School of Medicine, University of Utah, Salt Lake City, UT
| | - Sama Kamal
- Department of Surgery, School of Medicine, University of Utah, Salt Lake City, UT
| | - Liberato Marzullo
- BIOUNIVERSA s.r.l., Baronissi, Italy
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana” University of Salerno, Baronissi, Italy
| | - Margot De Marco
- BIOUNIVERSA s.r.l., Baronissi, Italy
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana” University of Salerno, Baronissi, Italy
| | - Antonia Falco
- BIOUNIVERSA s.r.l., Baronissi, Italy
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana” University of Salerno, Baronissi, Italy
| | - Armando Genovese
- University Hospital “San Giovanni di Dio e Ruggi D'Aragona,” Salerno, Italy
| | - Jessica M. Adler
- Department of Surgery, School of Medicine, University of Utah, Salt Lake City, UT
| | - Vincenzo De Laurenzi
- BIOUNIVERSA s.r.l., Baronissi, Italy
- Department of Medicine and Biotechnology, University G d'Annunzio and CeSI-MeT, Chieti, Italy
| | - Douglas G. Adler
- Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, UT
| | - Kajsa E. Affolter
- Department of Pathology, School of Medicine, University of Utah, Salt Lake City, UT
| | - Ignacio Garrido-Laguna
- Department of Oncological Sciences, School of Medicine, University of Utah, Salt Lake City, UT
| | - Courtney L. Scaife
- Department of Surgery, School of Medicine, University of Utah, Salt Lake City, UT
| | - M. Caterina Turco
- BIOUNIVERSA s.r.l., Baronissi, Italy
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana” University of Salerno, Baronissi, Italy
| | - Sean J. Mulvihill
- Department of Surgery, School of Medicine, University of Utah, Salt Lake City, UT
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8
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Ramia JM, Cugat E, De la Plaza R, Gomez-Bravo MA, Martín E, Muñoz-Bellvis L, Padillo FJ, Sabater L, Serradilla-Martín M. Clinical decisions in pancreatic cancer surgery: a national survey and case-vignette study. Updates Surg 2023; 75:115-131. [PMID: 36376560 DOI: 10.1007/s13304-022-01415-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 10/31/2022] [Indexed: 11/16/2022]
Abstract
Very few surveys have been carried out of oncosurgical decisions made in patients with pancreatic cancer (PC), or of the possible differences in therapeutic approaches between low/medium and high-volume centers. A survey was sent out to centers affiliated to the Spanish Group of Pancreatic Surgery (GECP) asking about their usual pre-, intra- and post-operative management of PC patients and describing five imaginary cases of PC corresponding to common scenarios that surgeons regularly assess in oncosurgical meetings. A consensus was considered to have been reached when 80% of the answers coincided. We received 69 responses from the 72 GECP centers (response rate 96%). Pre-operative management: consensus was obtained on 7/16 questions (43.75%) with no significant differences between low- vs high-volume centers. Intra-operative: consensus was obtained on 11/28 questions (39.3%). D2 lymphadenectomy, biliary culture, intra-operative biliary margin study, pancreatojejunostomy, and two loops were significantly more frequent in high-volume hospitals (p < 0.05). Post-operative: consensus was obtained on 2/8 questions (25%). No significant differences were found between low-/medium- vs high-volume hospitals. Of the 41 questions asked regarding the cases, consensus was reached on 22 (53.7%). No differences in the responses were found according to the type of hospital. Management and cases: consensus was reached in 42/93 questions (45.2%). At GECP centers, consensus was obtained on 45% of the questions. Only 5% of the answers differed between low/medium and high-volume centers (all intra-operative). A more specific assessment of why high-volume centers obtain the best results would require the design of complex prospective studies able to measure the therapeutic decisions made and the effectiveness of their execution. Clinicaltrials.gov identifier: NCT04755036.
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Affiliation(s)
- Jose M Ramia
- Department of Surgery, Hospital General Universitario de Alicante, Sol Naciente 8, 16D, 03016, Alicante, Spain. .,Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain.
| | - Esteban Cugat
- Department of Surgery, Hospital Universitario Germans Trias i Puyol and Hospital Universitario Mútua Terrassa, Barcelona, Spain
| | - Roberto De la Plaza
- Department of Surgery, Hospital Universitario de Guadalajara, Guadalajara, Spain
| | | | - Elena Martín
- Department of Surgery, Hospital Universitario La Princesa, Madrid, Spain
| | - Luis Muñoz-Bellvis
- Department of Surgery, University Hospital of Salamanca, Salamanca, Spain.,Institute of Biomedical Research of Salamanca (IBSAL), Universidad de Salamanca and Biomedical Research Networking Centre Consortium-CIBER-CIBERONC, Salamanca, Spain
| | - Francisco J Padillo
- Department of Surgery, Hospital Universitario Virgen del Rocio, Seville, Spain
| | - Luis Sabater
- Department of Surgery, Hospital Clínico, Biomedical Research Institute, University of Valencia, Valencia, Spain
| | - Mario Serradilla-Martín
- Department of Surgery, Instituto de Investigación Sanitaria Aragón, Hospital Universitario Miguel Servet, Zaragoza, Spain
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9
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Patient Perceptions of Decision-making and Quality-of-life Following Surgical Resection of Pancreatic Adenocarcinoma: A Mixed-methods Study. ANNALS OF SURGERY OPEN 2022; 3:e214. [PMID: 36590886 PMCID: PMC9780039 DOI: 10.1097/as9.0000000000000214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 09/05/2022] [Indexed: 01/03/2023] Open
Abstract
Pancreatic adenocarcinoma (PDAC) remains a highly lethal disease, with surgery, the only opportunity for cure, accompanied by high rates of morbidity. Understanding patients' lived experiences after surgical resection of PDAC is critical to knowing whether the decision to undergo surgery was worth it for these patients. Methods We performed a convergent, mixed-methods study with patients who underwent resection of PDAC between January 1, 2019, and January 8, 2020. Quantitative data (medical record review and 3 questionnaires) were analyzed using descriptive statistics. Qualitative data (semistructured interviews) were analyzed using the constant comparative method. Data were then compared for congruence. Results Eighteen of 22 eligible participants completed interviews and 11 completed questionnaires. Data collection occurred at a median of 14.2 months (IQR 11.6-16.3) from surgery. We identified 4 main themes. First, persistent negative symptoms were common for patients, but patients adapt to these and are satisfied with their "new normal." Second, patients have varied and continually evolving mindsets throughout their cancer journey. Third, despite decreased quality-of-life, patients have a high degree of satisfaction with their decision to pursue surgery. Finally, patients were okay with a passive role in decision-making around surgery. Despite variable involvement in decision-making and outcomes, no participants reported regret over the decision to pursue surgery. Discussion This nuanced account of patients' lived experiences following surgery for PDAC allows for an improved understanding of the impact of pancreatic resection on patients. Surgeons can use these data to improve preoperative counseling for patients with PDAC and help guide them to making the correct decisions about surgery.
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10
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McNeil LR, Blair AB, Krell RW, Zhang C, Ejaz A, Groot VP, Gemenetzis G, Padussis JC, Falconi M, Wolfgang CL, Weiss MJ, Are C, He J, Reames BN. Geographic variation in attitudes regarding management of locally advanced pancreatic cancer. Surg Open Sci 2022; 10:97-105. [PMID: 36062077 PMCID: PMC9436766 DOI: 10.1016/j.sopen.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 07/30/2022] [Indexed: 12/04/2022] Open
Abstract
Background Recent literature suggests wide variations exist in the international management of locally advanced pancreatic cancer. This study sought to evaluate how geography contributes to variations in management of locally advanced pancreatic cancer. Methods An electronic survey investigating preferences for the evaluation and management of locally advanced pancreatic cancer was distributed to an international cohort of pancreatic surgeons. Surgeons were classified according to geographic location of practice, and survey responses were compared across locations. Results A total of 153 eligible responses were received from 4 continents: North and South America (n = 94, 61.4%), Europe (n = 25, 16.3%), and Asia (n = 34, 22.2%). Preferences for the use and duration of neoadjuvant chemotherapy and radiotherapy varied widely. For example, participants in Asia commonly preferred 2 months of neoadjuvant chemotherapy (61.8%), whereas North and South American participants preferred 4 months (52.1%), and responses in Europe were mixed (P = .006). Participants in Asia were less likely to consider isolated liver or lung metastases contraindications to exploration and consequently had a greater propensity to consider exploration in a vignette of oligometastatic disease (56.7% vs North and South America: 25.6%, Europe: 43.5%; P = .007). Conclusion In an international survey of pancreatic surgeons, attitudes regarding locally advanced pancreatic cancer and metastatic disease management varied widely across geographic locations. Better evidence is needed to define optimal management of locally advanced pancreatic cancer.
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Affiliation(s)
- Logan R. McNeil
- College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Alex B. Blair
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Robert W. Krell
- Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Chunmeng Zhang
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Aslam Ejaz
- Department of Surgery, Ohio State University, Columbus, OH, USA
| | - Vincent P. Groot
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Georgios Gemenetzis
- Department of Surgery, University of Glasgow School of Medicine, Glasgow, UK
| | - James C. Padussis
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Massimo Falconi
- Department of Surgery, Università Vita-Salute, San Raffaele Hospital IRCCS, Milano, Italy
| | | | | | - Chandrakanth Are
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Jin He
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Bradley N. Reames
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
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11
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Hyman DW, Almerey T, Mujkanovic A, Hammons I, Tice M, Stauffer JA. Comparing Post-Operative Outcomes of Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma: Neoadjuvant Therapy Versus Surgery First Approach. Am Surg 2022; 88:1868-1874. [PMID: 35465681 DOI: 10.1177/00031348221087900] [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] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Optimal use of surgery first (SF) vs neoadjuvant therapy (NAT) for localized pancreatic ductal adenocarcinoma (PDAC) is still unclear. There is concern that NAT may result in worsened post-operative outcomes. Our study objectives were to show the impact of NAT on post-operative morbidity and mortality. METHODS All patients undergoing resection for PDAC between 1/1/2010 and 12/31/2020 were reviewed and those who underwent pancreaticoduodenectomy (PD) were included. Demographics, perioperative details, and pathology details were gathered. Data pertaining to 90-day complications were obtained and graded according to international consensus guidelines. Those undergoing SF were compared to those who had NAT. Categorical variables were compared by Fisher's exact test and continuous variables by Student's t-test. RESULTS Two hundred and forty-one subjects who underwent PD for PDAC were included in this review. There was no significant difference in the rate of major morbidity between subjects who received NAT vs SF (19.4 vs 20.3%, P = 1.0). Similarly, there were no significant differences in the rates of mortality (3.1 vs 4.2%, P = .742), post-operative pancreatic fistula (8.2 vs 10.5%, P = .658), or post-pancreatectomy hemorrhage (7.1 vs 7.7%, P = 1.0), respectively. CONCLUSION Post-operative outcomes are not worsened by the use of the NAT approach prior to PD for PDAC. Further investigation is needed to reveal which patient subgroups may benefit from the use of NAT, especially regarding survival.
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Affiliation(s)
- David W Hyman
- Department of Surgery, 23389Mayo Clinic, Jacksonville, FL, USA
| | - Tariq Almerey
- Department of Surgery, 23389Mayo Clinic, Jacksonville, FL, USA
| | - Amer Mujkanovic
- Department of Surgery, 23389Mayo Clinic, Jacksonville, FL, USA
| | - Isaac Hammons
- Department of Surgery, 23389Mayo Clinic, Jacksonville, FL, USA
| | - Mary Tice
- Department of Surgery, 23389Mayo Clinic, Jacksonville, FL, USA
| | - John A Stauffer
- Department of Surgery, 23389Mayo Clinic, Jacksonville, FL, USA
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12
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Turner KM, Delman AM, Kharofa JR, Smith MT, Choe KA, Olowokure O, Wilson GC, Patel SH, Sohal D, Ahmad SA. Radiation therapy in borderline resectable pancreatic cancer: A review. Surgery 2022; 172:284-290. [PMID: 35034793 DOI: 10.1016/j.surg.2021.12.013] [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: 10/07/2021] [Revised: 11/11/2021] [Accepted: 12/14/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Borderline resectable pancreatic cancer constitutes a complex clinical entity, presenting the clinician with a locally aggressive disease that has a proclivity for distant spread. The benefits of radiation therapy, such as improved local control and improved survival, have been questioned. In this review we seek to summarize the existing evidence on radiation therapy in borderline resectable pancreatic cancer and highlight future areas of research. METHODS A comprehensive review of PubMed for clinical studies reporting outcomes in borderline resectable pancreatic cancer was performed in June 2021, with an emphasis placed on prospective studies. RESULTS Radiologic "downstaging" in borderline resectable pancreatic cancer is a rare event, although some evidence shows increased clinical response to neoadjuvant chemotherapy over radiation therapy. Margin status seems to be equivalent between regimens that use neoadjuvant chemotherapy alone and regimens that include neoadjuvant radiation therapy. Local control in borderline resectable pancreatic cancer is likely improved with radiation therapy; however, the benefit of improved local control in a disease marked by systemic failure has been questioned. Although some studies have shown improved survival with radiation therapy, differences in the delivery and tolerance of chemotherapy between the neoadjuvant and adjuvant setting confound these results. When the evidence is evaluated as a whole, there is no clear survival benefit of radiation therapy in borderline resectable pancreatic cancer. CONCLUSION Once considered a staple of therapy, the role of radiation therapy in borderline resectable pancreatic cancer is evolving as systemic therapy regimens continues to improve. Increased clinical understanding of disease phenotype and response are needed to accurately tailor therapy for individual patients and to improve outcomes in this complex patient population.
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Affiliation(s)
- Kevin M Turner
- Department of Surgery, University of Cincinnati College of Medicine, OH
| | - Aaron M Delman
- Department of Surgery, University of Cincinnati College of Medicine, OH
| | - Jordan R Kharofa
- Department of Radiation Oncology, University of Cincinnati College of Medicine, OH
| | - Milton T Smith
- Division of Digestive Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, OH
| | - Kyuran A Choe
- Department of Radiology, University of Cincinnati College of Medicine, OH
| | - Olugbenga Olowokure
- Division of Hematology & Oncology, Department of Internal Medicine, University of Cincinnati College of Medicine, OH
| | - Gregory C Wilson
- Department of Surgery, University of Cincinnati College of Medicine, OH; Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, OH
| | - Sameer H Patel
- Department of Surgery, University of Cincinnati College of Medicine, OH; Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, OH
| | - Davendra Sohal
- Division of Hematology & Oncology, Department of Internal Medicine, University of Cincinnati College of Medicine, OH
| | - Syed A Ahmad
- Department of Surgery, University of Cincinnati College of Medicine, OH; Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, OH.
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13
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Ofri A, Zuidersma D, Diakos CI, Stevanovic A, Wong M, Sood S, Samra JS, Gill AJ, Mittal A. Synchronous Operable Pancreatic and Breast Cancer Without Genetic Mutation: A Literature Review and Discussion. Front Surg 2022; 9:858349. [PMID: 35813042 PMCID: PMC9263594 DOI: 10.3389/fsurg.2022.858349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 06/06/2022] [Indexed: 11/21/2022] Open
Abstract
Background Synchronous cancers are rarely detected when working-up a patient for a primary cancer. Neoadjuvant management of synchronous breast and pancreatic cancers, without a germline mutation, has yet to be discussed. Two patients were diagnosed with synchronous breast and pancreatic cancers at our institution over the last decade. A literature review was performed to evaluate the current evidence stance. Results The first patient was 61-years old and diagnosed with a HER2+ breast cancer. The second patient was 77-years old and diagnosed with a Luminal B breast cancer. The inability to provide concurrent breast and pancreatic neoadjuvant therapy for the HER2+ patient, resulted in upfront surgery. The second patient was able to have both cancers treated simultaneously - neoadjuvant chemotherapy to the pancreas, and neoadjuvant endocrine therapy to the breast. Discuss There is no single neoadjuvant regimen that treats both pancreatic and breast cancer. The differences in breast cancer sub-types impacted our neoadjuvant options. Our recent experience led us to the hypothesis that breast cancer care dictates treatment, while pancreatic cancer determines survival. There is a significant paucity in the literature regarding synchronous breast and pancreatic cancer.
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Affiliation(s)
- Adam Ofri
- Department of Surgery, Sir Charles Gairdner Hospital, Nedlands, Australia
- St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - Danika Zuidersma
- Department of Surgery, Sir Charles Gairdner Hospital, Nedlands, Australia
| | - Connie I Diakos
- Kolling Institute of Medical Research, University of Sydney, Sydney, Australia
- Department of Medical Oncology, Royal North Shore Hospital, St Leonards, Australia
| | - Amanda Stevanovic
- Department of Medical Oncology, Nepean Cancer Care Centre, Nepean, Australia
| | - Matthew Wong
- Central Coast Cancer Centre, Gosford Hospital, Gosford, Australia
| | - Samriti Sood
- Department of Breast Surgery, Royal North Shore Hospital, St Leonards, Australia
| | - Jaswinder S Samra
- Kolling Institute of Medical Research, University of Sydney, Sydney, Australia
- Upper GI Surgical Unit, Royal North Shore Hospital and North Shore Private Hospital, St Leonards,Australia
- Australian Pancreatic Centre, St Leonards, Sydney, Australia
- Northern Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- School of Medicine, Macquarie University, Sydney, Australia
| | - Anthony J Gill
- Kolling Institute of Medical Research, University of Sydney, Sydney, Australia
- Northern Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- NSW Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, St Leonards, Australia
| | - Anubhav Mittal
- Kolling Institute of Medical Research, University of Sydney, Sydney, Australia
- Upper GI Surgical Unit, Royal North Shore Hospital and North Shore Private Hospital, St Leonards,Australia
- Australian Pancreatic Centre, St Leonards, Sydney, Australia
- Northern Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- School of Medicine, University of Notre Dame, Sydney, Australia
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14
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Gugenheim J, Crovetto A, Petrucciani N. Neoadjuvant therapy for pancreatic cancer. Updates Surg 2022; 74:35-42. [PMID: 34628591 PMCID: PMC8502083 DOI: 10.1007/s13304-021-01186-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 09/30/2021] [Indexed: 12/12/2022]
Abstract
Multimodal treatment including surgery and chemotherapy is considered the gold standard treatment of pancreatic cancer by most guidelines. Neoadjuvant therapy (NAT) has been seen as a possible treatment option for resectable, borderline resectable and locally advanced PaC. The aim of this paper is to offer a state-of-the-art review on neoadjuvant treatments in the setting of pancreatic ductal adenocarcinoma. A systematic literature search was performed using PubMed, Cochrane, Web of Science and Embase databases, in order to identify relevant studies published up to and including July 2021 that reported and analyzed the role of neoadjuvant therapy in the setting of pancreatic carcinoma. Most authors are concordant on the strong role of neoadjuvant therapy in the setting of borderline resectable pancreatic cancers. Recent randomized trials demonstrated improvement of R0 rate and survival after NAT in this setting. Patients with locally advanced cancers may become resectable after NAT, with better results than those obtained with palliative therapies. Even in the setting of resectable cancers, NAT is being evaluated by ongoing randomized trials. Chemotherapy regimens in the setting of NAT and response to NAT are discussed. NAT has an important role in the multimodal treatment of patients with borderline resectable pancreatic cancer. It has a role in patients with locally advanced tumors as it can allow surgical resection in a relevant proportion of patients. For resectable pancreatic cancers, the role of NAT is under evaluation by several randomized trials.
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Affiliation(s)
- Jean Gugenheim
- Université Côte d'Azur, Nice, France.
- Division of Digestive Surgery and Liver Transplantation, Archet 2 Hospital, University Hospital of Nice, 151 Route de Saint-Antoine, 06200, Nice, France.
| | - Anna Crovetto
- Faculty of Medicine and Psychology, Department of Medical and Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Niccolo Petrucciani
- Faculty of Medicine and Psychology, Department of Medical and Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
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15
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Blair AB, Krell RW, Ejaz A, Groot VP, Gemenetzis G, Padussis JC, Falconi M, Wolfgang CL, Weiss MJ, Are C, He J, Reames BN. Proclivity to Explore Locally Advanced Pancreas Cancer Is Not Associated with Surgeon Volume. J Gastrointest Surg 2021; 25:2562-2571. [PMID: 34027578 DOI: 10.1007/s11605-021-05034-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 04/28/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND PURPOSE There is limited high-level evidence to guide locally advanced pancreas cancer (LAPC) management. Recent work shows that surgeons' preferences in LAPC management vary broadly. We sought to examine whether surgeon volume was associated with attitudes regarding LAPC management. METHODS An electronic survey was distributed by email to an international cohort of pancreas surgeons to evaluate practice patterns regarding LAPC management. Clinical vignette-based questions evaluated surgeons' attitudes regarding patient eligibility and the proclivity to offer exploration. Surgeons were classified into "low-" or "high-volume" categories according to thresholds of self-reported annual pancreatectomy volume. Surgeon's attitudes regarding LAPC management and inclination to consider exploration were compared across annual volume categories. RESULTS A total of 153 eligible responses were received from 4 continents, for an estimated response rate of 10.6%. Median duration of practice was 12 years (IQR 6-20). Most respondents reported >25 cases/year (89, 58.2%), of which 34 (22.2%) reported >50. Compared to surgeons with <25 cases/year, surgeons with >25 cases/year practiced longer (median 15 vs. 7.5 years, P<0.001) and were more likely to "always" recommend neoadjuvant chemotherapy (83.2% vs. 56.3%, P=0.001). Surgeons performing >50 cases/year were more likely to offer arterial resection (70.6% vs. 43.7%, P=0.006). The willingness to offer (or defer) exploration did not differ across any categories of surgeons' annual case volume. CONCLUSIONS In an international survey of pancreas surgeons, the proclivity to consider exploration for LAPC was not associated with multiple categories of surgeon volume. Better evidence is needed to define the optimal management approach to LAPC.
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Affiliation(s)
- Alex B Blair
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Robert W Krell
- Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Aslam Ejaz
- Department of Surgery, Ohio State University, Columbus, OH, USA
| | - Vincent P Groot
- Department of Surgery, UMC Utrecht Cancer Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Georgios Gemenetzis
- Department of Surgery, University of Glasgow School of Medicine, Glasgow, UK
| | - James C Padussis
- Department of Surgery, Division of Surgical Oncology, University of Nebraska Medical Center, 986880 Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Massimo Falconi
- Department of Surgery, Università Vita-Salute, San Raffaele Hospital IRCCS, Milano, Italy
| | | | | | - Chandrakanth Are
- Department of Surgery, Division of Surgical Oncology, University of Nebraska Medical Center, 986880 Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Jin He
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Bradley N Reames
- Department of Surgery, Division of Surgical Oncology, University of Nebraska Medical Center, 986880 Nebraska Medical Center, Omaha, NE, 68198, USA.
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16
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Almadi MA, Gardner TB, Chen YI, Adam V, Barkun J, Barkun A. Use of stents in patients undergoing chemotherapy for borderline resectable pancreatic cancer-causing biliary obstruction while awaiting surgery: A cost-effectiveness analysis. Endosc Int Open 2021; 9:E1413-E1420. [PMID: 34466367 PMCID: PMC8382504 DOI: 10.1055/a-1497-1562] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 04/20/2021] [Indexed: 10/31/2022] Open
Abstract
Background and study aims Biliary stenting is indicated to relieve obstruction from borderline resectable pancreatic cancer while patients receive preoperative neoadjuvant therapy. We compared the cost-effectiveness of plastic versus metal biliary stenting in this setting. Methods A decision tree analysis compares two competing types of biliary stents (initially metal vs. initially plastic) to treat malignant distal biliary obstruction while receiving neoadjuvant therapy with different scenarios including possible complications as bridge till the patient undergoes curative surgical attempt. Using published information, effectiveness was chosen as the probability of successfully reaching a state of being ready for surgery once chemotherapy was completed. Costs (2018 US$) were based on national data. A third-party payer perspective was adopted, and sensitivity analyses were performed over a time-horizon of one year. Results Initially inserting a metal versus a plastic biliary stent was more efficacious with a higher probability of reaching the readiness for surgery endpoint (96 % vs. 85 %), on average 18 days earlier while also being less expensive (US$ 9,304 vs. US$ 11,538). Sensitivity analyses confirmed robustness of these results across varying probability assumptions of plausible ranges and remained a dominant strategy even when lowering the willingness-to-pay threshold to US$ 1,000. Conclusions Initial metal stenting to relieve malignant biliary obstruction from borderline resectable pancreatic cancer in patients undergoing neoadjuvant therapy prior to surgery is a dominant intervention in economic terms, when compared to initially inserting a plastic biliary stent as it results in a greater proportion of patients being fit for surgery earlier and at a lower cost.
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Affiliation(s)
- Majid A Almadi
- Division of Gastroenterology, McGill University Health Centre, McGill University, Montréal, Québec, Canada
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Timothy B Gardner
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, United States
| | - Yen-I Chen
- Division of Gastroenterology, McGill University Health Centre, McGill University, Montréal, Québec, Canada
| | - Viviane Adam
- Division of Gastroenterology, McGill University Health Centre, McGill University, Montréal, Québec, Canada
| | - Jeffrey Barkun
- Department of Surgery, McGill University Health Centre, McGill University, Montréal, Québec, Canada
| | - Alan Barkun
- Division of Gastroenterology, McGill University Health Centre, McGill University, Montréal, Québec, Canada
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17
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Hamad A, Brown ZJ, Ejaz AM, Dillhoff M, Cloyd JM. Neoadjuvant therapy for pancreatic ductal adenocarcinoma: Opportunities for personalized cancer care. World J Gastroenterol 2021; 27:4383-4394. [PMID: 34366611 PMCID: PMC8316910 DOI: 10.3748/wjg.v27.i27.4383] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/12/2021] [Accepted: 07/05/2021] [Indexed: 02/06/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy that is best treated in a multidisciplinary fashion using surgery, chemotherapy, and radiation. Adjuvant chemotherapy has shown to have a significant survival benefit in patients with resected PDAC. However, up to 50% of patients fail to receive adjuvant chemotherapy due to postoperative complications, poor patient performance status or early disease progression. In order to ensure the delivery of chemotherapy, an alternative strategy is to administer systemic treatment prior to surgery. Precision oncology refers to the application of diverse strategies to target therapies specific to characteristics of a patient’s cancer. While traditionally emphasized in selecting targeted therapies based on molecular, genetic, and radiographic biomarkers for patients with metastatic disease, the neoadjuvant setting is a prime opportunity to utilize personalized approaches. In this article, we describe the current evidence for the use of neoadjuvant therapy (NT) and highlight unique opportunities for personalized care in patients with PDAC undergoing NT.
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Affiliation(s)
- Ahmad Hamad
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43215, United States
| | - Zachary J Brown
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43215, United States
| | - Aslam M Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43215, United States
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43215, United States
| | - Jordan M Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43215, United States
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18
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Reames BN, Blair AB, Krell RW, Groot VP, Gemenetzis G, Padussis JC, Thayer SP, Falconi M, Wolfgang CL, Weiss MJ, Are C, He J. Management of Locally Advanced Pancreatic Cancer: Results of an International Survey of Current Practice. Ann Surg 2021; 273:1173-1181. [PMID: 31449138 DOI: 10.1097/sla.0000000000003568] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The aim of this study was to investigate surgeon preferences for the management of patients with locally advanced pancreatic cancer (LAPC). BACKGROUND Select patients with LAPC may become candidates for curative resection following neoadjuvant therapy, and recent reports of survival are encouraging. Yet the optimal management approach remains unclear. METHODS An extensive electronic survey was systematically distributed by email to an international cohort of pancreas surgeons. Data collected included practice characteristics, management preferences, attitudes regarding contraindications to surgery, and 6 clinical vignettes of patients that ultimately received a margin negative resection (with detailed videos of post-neoadjuvant imaging) to assess propensity for surgical exploration if resection status is not known. RESULTS A total of 153 eligible responses were received from 4 continents. Median duration of practice is 12 years (interquartile range 6-20) and 77% work in a university setting. Most surgeons (86%) are considered high volume (>10 resections/yr), 33% offer a minimally-invasive approach, and 50% offer arterial resections in select patients. Most (72%) always recommend neoadjuvant chemotherapy, and 65% prefer FOLFIRINOX. Preferences for the duration of chemotherapy varied widely: 39% prefer ≥2 months, 43% prefer ≥4 months, and 11% prefer ≥6 months. Forty-one percent frequently recommend neoadjuvant radiotherapy, and 53% prefer 5 to 6 weeks of chemoradiation. The proportion of surgeons favoring exploration following neoadjuvant varied extensively across 5 vignettes of LAPC, from 14% to 53%. In a vignette of oligometastatic liver metastases, 31% would offer exploration if a favorable therapy response is observed. CONCLUSIONS In an international cohort of pancreas surgeons, there is substantial variation in management preferences, perceived contraindications to surgery, and the propensity to consider exploration in LAPC. These results emphasize the importance of a robust and nuanced multidisciplinary discussion for each patient, and suggest an evolving concept of "resectability."
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Affiliation(s)
- Bradley N Reames
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Alex B Blair
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Robert W Krell
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Vincent P Groot
- Department of Surgery, UMC Utrecht Cancer Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Georgios Gemenetzis
- Department of Surgery, University of Glasgow School of Medicine, Glasgow, UK
| | - James C Padussis
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Sarah P Thayer
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Massimo Falconi
- Department of Surgery, Università Vita-Salute, San Raffaele Hospital IRCCS, Milano, Italy
| | | | | | - Chandrakanth Are
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Jin He
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
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19
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Datta J, Willobee BA, Ryon EL, Shah MM, Drebin JA, Kooby DA, Merchant NB. Contemporary Reappraisal of Intraoperative Neck Margin Assessment During Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma: A Review. JAMA Surg 2021; 156:489-495. [PMID: 33533898 DOI: 10.1001/jamasurg.2020.5676] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance Although margin-negative (R0) resection is the gold standard for surgical management of localized pancreatic ductal adenocarcinoma (PDAC), the question of how to manage the patient with a microscopically positive intraoperative neck margin (IONM) during pancreaticoduodenectomy remains controversial. Observations In the absence of randomized clinical trials, we critically evaluated high-quality retrospective studies examining the oncologic utility of re-resecting positive IONMs during pancreaticoduodenectomy for PDAC (2000-2019). Several studies have concluded that additional pancreatic resection to achieve an R0 margin in IONM-positive cases does not influence survival. The largest is a multi-institutional study of 1399 patients undergoing pancreaticoduodenectomy, which demonstrated that in comparison with patients undergoing R0 resection (n = 1196; median survival, 21 months), those with either final R1 resections (n = 131) or undergoing margin conversion from IONM-positive to R0 resection on permanent section (n = 72) demonstrated similar median survival times (13.7 and 11.9 months, respectively). Conversely, recent reports suggest that the conversion of IONM to R0 resection with additional resection or even total pancreatectomy may be associated with improved survival. The discordance between these conflicting studies could be explained in part by the influence of biologic and physiologic selection on the association of IONM re-resection and survival. Since most studies did not include patients receiving modern combination chemotherapy regimens, the intersection between margin status, tumor biology, and chemoresponsiveness remains unclear. Furthermore, there are no dedicated data to guide surgical management in IONM-positive pancreaticoduodenectomy for patients receiving neoadjuvant chemotherapy. Conclusions and Relevance Although data regarding the oncologic utility of additional resection to achieve a tumor-free margin following initial IONM positivity during pancreaticoduodenectomy for PDAC are conflicting, they suggest that IONM positivity may be a surrogate for biologic aggressiveness that is unlikely to be mitigated by the extent of surgical resection. The complex relationship between margin status and chemoresponsiveness warrants exploration in studies including patients receiving increasingly effective neoadjuvant chemotherapy.
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Affiliation(s)
- Jashodeep Datta
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida.,Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Brent A Willobee
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Emily L Ryon
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Mihir M Shah
- Winship Cancer Institute, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Jeffrey A Drebin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David A Kooby
- Winship Cancer Institute, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Nipun B Merchant
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida.,Sylvester Comprehensive Cancer Center, Miami, Florida
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20
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Casolino R, Braconi C, Malleo G, Paiella S, Bassi C, Milella M, Dreyer SB, Froeling FEM, Chang DK, Biankin AV, Golan T. Reshaping preoperative treatment of pancreatic cancer in the era of precision medicine. Ann Oncol 2021; 32:183-196. [PMID: 33248227 PMCID: PMC7840891 DOI: 10.1016/j.annonc.2020.11.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/16/2020] [Accepted: 11/17/2020] [Indexed: 12/11/2022] Open
Abstract
This review summarises the recent evidence on preoperative therapeutic strategies in pancreatic cancer and discusses the rationale for an imminent need for a personalised therapeutic approach in non-metastatic disease. The molecular diversity of pancreatic cancer and its influence on prognosis and treatment response, combined with the failure of 'all-comer' treatments to significantly impact on patient outcomes, requires a paradigm shift towards a genomic-driven approach. This is particularly important in the preoperative, potentially curable setting, where a personalised treatment allocation has the substantial potential to reduce pancreatic cancer mortality.
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Affiliation(s)
- R Casolino
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Bearsden, Glasgow, Scotland, UK; Department of Medicine, University and Hospital Trust of Verona, Verona, Italy
| | - C Braconi
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Bearsden, Glasgow, Scotland, UK
| | - G Malleo
- Department of Surgery, University and Hospital Trust of Verona, Verona, Italy
| | - S Paiella
- Department of Surgery, University and Hospital Trust of Verona, Verona, Italy
| | - C Bassi
- Department of Surgery, University and Hospital Trust of Verona, Verona, Italy
| | - M Milella
- Department of Medicine, Medical Oncology, University and Hospital Trust of Verona, Verona (VR), Italy
| | - S B Dreyer
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Bearsden, Glasgow, Scotland, UK; West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - F E M Froeling
- Edinburgh Cancer Centre, Western General Hospital, NHS Lothian, Edinburgh, UK
| | - D K Chang
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Bearsden, Glasgow, Scotland, UK; West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - A V Biankin
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Bearsden, Glasgow, Scotland, UK; West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK; South Western Sydney Clinical School, Faculty of Medicine, University of NSW, Liverpool, NSW, Australia.
| | - T Golan
- Oncology Institute, Sheba Medical Center, Tel Hashomer, Israel
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21
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Søreide K. Neoadjuvant and Adjuvant Therapy in Operable Pancreatic Cancer: Both Honey and Milk (but No Bread?). Oncol Ther 2021; 9:1-12. [PMID: 33439449 PMCID: PMC8140001 DOI: 10.1007/s40487-020-00136-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 12/18/2020] [Indexed: 12/20/2022] Open
Abstract
Pancreatic cancer has a dismal prognosis. Resection is the best option for cure, supported by multimodal therapy to treat the systemic disease. While adjuvant therapy has become standard in those who are fit and who can tolerate the given regimen, the concept of perioperative (neoadjuvant) therapy is building momentum. The concepts of “borderline” and “locally advanced” have changed the previous dichotomized “resectable/non-resectable” into subcategories for which new algorithms have emerged, with neoadjuvant therapy discussed both for upfront resectable pancreatic cancer, for those deemed borderline resectable, and as “induction or conversion” therapy for locally advanced disease. The purpose of this invited commentary is to discuss some of the changing paradigms in multimodal therapy for operable pancreatic cancer. The PREOPANC trial presented randomized data on the role of neoadjuvant therapy for resectable and borderline cancers, but new questions have emerged. The role of combination therapy in the preoperative setting is discussed in the light of this trial. FOLFIRINOX has emerged as the most potent treatment regimen in the metastatic and adjuvant setting, but with no level I data to support neoadjuvant use yet. Several trials are ongoing to arrive at the best answer.
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Affiliation(s)
- Kjetil Søreide
- -Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway.
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.
- Gastrointestinal Translation Research Unit, Stavanger University Hospital, Stavanger, Norway.
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22
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O'Connor D, Brown M, Eatock M, Turkington RC, Prue G. Exercise efficacy and prescription during treatment for pancreatic ductal adenocarcinoma: a systematic review. BMC Cancer 2021; 21:43. [PMID: 33422020 PMCID: PMC7794639 DOI: 10.1186/s12885-020-07733-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 12/14/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Surgical resection remains the only curative treatment for pancreatic cancer and is associated with significant post-operative morbidity and mortality. Patients eligible for surgery, increasingly receive neo-adjuvant therapy before surgery or adjuvant therapy afterward, inherently exposing them to toxicity. As such, optimizing physical function through exercise during treatment remains imperative to optimize quality of life either before surgery or during rehabilitation. However, current exercise efficacy and prescription in pancreatic cancer is unknown. Therefore, this study aims to summarise the published literature on exercise studies conducted in patients with pancreatic cancer undergoing treatment with a focus on determining the current prescription and progression patterns being used in this population. METHODS A systematic review of four databases identified studies evaluating the effects of exercise on aerobic fitness, muscle strength, physical function, body composition, fatigue and quality of life in participants with pancreatic cancer undergoing treatment, published up to 24 July 2020. Two reviewers independently reviewed and appraised the methodological quality of each study. RESULTS Twelve studies with a total of 300 participants were included. Heterogeneity of the literature prevented meta-analysis. Exercise was associated with improvements in outcomes; however, study quality was variable with the majority of studies receiving a weak rating. CONCLUSIONS High quality evidence regarding the efficacy and prescription of exercise in pancreatic cancer is lacking. Well-designed trials, which have received feedback and input from key stakeholders prior to implementation, are required to examine the impact of exercise in pancreatic cancer on key cancer related health outcomes.
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Affiliation(s)
- Dominic O'Connor
- School of Nursing and Midwifery, Queen's University, 8 Fitzwilliam Street, Belfast, Northern Ireland, BT9 6AW, UK.
| | - Malcolm Brown
- School of Nursing and Midwifery, Queen's University, 8 Fitzwilliam Street, Belfast, Northern Ireland, BT9 6AW, UK
| | - Martin Eatock
- The Northern Ireland Cancer Centre, Belfast City Hospital, Belfast, Northern Ireland
- The Patrick G Johnston Centre for Cancer Research, Queen's University, Belfast, Northern Ireland
| | - Richard C Turkington
- The Northern Ireland Cancer Centre, Belfast City Hospital, Belfast, Northern Ireland
- The Patrick G Johnston Centre for Cancer Research, Queen's University, Belfast, Northern Ireland
| | - Gillian Prue
- School of Nursing and Midwifery, Queen's University, 8 Fitzwilliam Street, Belfast, Northern Ireland, BT9 6AW, UK
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23
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Zharikov YO, Zemlyakova SS, Kiseleva YV, Zharikova TS, Antonyan SG, Tupikin KA, Nikolenko VN. Pancreatic Cancer: Statistics And Treatment In The Russian Federation. RUSSIAN OPEN MEDICAL JOURNAL 2020. [DOI: 10.15275/rusomj.2020.0415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Pancreatic cancer (PC) is one of the most fatal types of oncological disease in the world and is an extremely aggressive cancer with a poor prognosis. The objective of this review was to analyze the domestic data of the incidence of PC in the Russian Federation and to analyze the protocols that are used for the management of this group of patients in Russian clinical centers. For the analysis of the literature sources, the data in the elibrary.ru database published in the period from 2015 to 2019 were used. The methodology that was used in each study was examined in order to ensure its reliability, and these data were selected as potential sources of evidence for the preparation of national recommendations. The study results influence the level of evidence assigned to the publication. Updates to the national recommendations are conducted at least once every three years, and these updates depend on new information about the diagnosis and management of patients with PC.
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24
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Müller PC, Frey MC, Ruzza CM, Nickel F, Jost C, Gwerder C, Hackert T, Z'graggen K, Kessler U. Neoadjuvant Chemotherapy in Pancreatic Cancer: An Appraisal of the Current High-Level Evidence. Pharmacology 2020; 106:143-153. [PMID: 32966993 DOI: 10.1159/000510343] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 07/20/2020] [Indexed: 01/11/2023]
Abstract
At the time of diagnosis, only about 20% of patients with pancreatic ductal adenocarcinoma (PDAC) have resectable disease. PDAC treatment necessitates a multidisciplinary approach, and adjuvant chemotherapy after upfront resection is an established means of preventing recurrence. Neoadjuvant chemotherapy (NAT), originally introduced to downstage tumor size, is nowadays more frequently used for selection of patients with favorable tumor biology and to control potential micrometastases. While NAT is routinely applied in locally advanced (LA) PDAC, there is increasing evidence demonstrating benefits of NAT in borderline resectable (BR) PDAC. The concept of NAT has recently been tested in resectable PDAC, but to date NAT has been restricted to clinical trials, as the data are limited and no clear benefits have yet been shown in this patient group. This review summarizes the current evidence for NAT in resectable, BR, and LA PDAC, with a focus on high-level evidence and randomized controlled trials.
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Affiliation(s)
- Philip C Müller
- Department of Surgery, Hirslanden Klinik Beau-Site, Bern, Switzerland.,Swiss Pancreas Center, Hirslanden Klinik Beau-Site, Bern, Switzerland
| | - Michael C Frey
- Swiss Pancreas Center, Hirslanden Klinik Beau-Site, Bern, Switzerland.,Department of Pediatric Surgery, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Claudio M Ruzza
- Department of Surgery, Hirslanden Klinik Beau-Site, Bern, Switzerland.,Swiss Pancreas Center, Hirslanden Klinik Beau-Site, Bern, Switzerland
| | - Felix Nickel
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Christian Jost
- Swiss Pancreas Center, Hirslanden Klinik Beau-Site, Bern, Switzerland.,Department of Gastroenterology, Hirslanden Klinik Beau-Site, Bern, Switzerland
| | - Christoph Gwerder
- Swiss Pancreas Center, Hirslanden Klinik Beau-Site, Bern, Switzerland.,Department of Oncology, Hirslanden Klinik Beau-Site, Bern, Switzerland
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Kaspar Z'graggen
- Department of Surgery, Hirslanden Klinik Beau-Site, Bern, Switzerland, .,Swiss Pancreas Center, Hirslanden Klinik Beau-Site, Bern, Switzerland,
| | - Ulf Kessler
- Department of Surgery, Hirslanden Klinik Beau-Site, Bern, Switzerland.,Swiss Pancreas Center, Hirslanden Klinik Beau-Site, Bern, Switzerland.,Department of Pediatric Surgery, University Hospital Bern, University of Bern, Bern, Switzerland
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25
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Open and Minimal Approaches to Pancreatic Adenocarcinoma. Gastroenterol Res Pract 2020; 2020:4162657. [PMID: 32565781 PMCID: PMC7273371 DOI: 10.1155/2020/4162657] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 11/01/2019] [Indexed: 12/24/2022] Open
Abstract
Surgical options and approaches to pancreatic cancer are changing in the current era. Neoadjuvant treatment strategies for pancreatic cancer combined with the increased use of minimal access surgical techniques mean that the modern pancreatic surgeon requires mastering a number of surgical approaches with to optimally manage patients. Whilst traditional open surgery remains the most frequent approach for surgery, the specific steps during surgery may need to be modified in light of the aforementioned neoadjuvant treatments. Robotic and laparoscopic approaches to pancreatic resection are feasible, but these surgical methods remain in their infancy. In this review article, we summarise the current surgical approaches to pancreatic cancer and how these are adapted to the minimal access setting with discussion of the patient outcome data.
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26
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Pancreatic Cancer Associated Fibroblasts (CAF): Under-Explored Target for Pancreatic Cancer Treatment. Cancers (Basel) 2020; 12:cancers12051347. [PMID: 32466266 PMCID: PMC7281461 DOI: 10.3390/cancers12051347] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/12/2020] [Accepted: 05/19/2020] [Indexed: 02/07/2023] Open
Abstract
Pancreatic cancer is the 4th leading cause of cancer deaths in the United States. The pancreatic cancer phenotype is primarily a consequence of oncogenes disturbing the resident pancreas parenchymal cell repair program. Many solid tumor types including pancreatic cancer have severe tumor fibrosis called desmoplasia. Desmoplastic stroma is coopted by the tumor as a support structure and CAFs aid in tumor growth, invasion, and metastases. This stroma is caused by cancer associated fibroblasts (CAFs), which lay down extensive connective tissue in and around the tumor cells. CAFs represent a heterogeneous population of cells that produce various paracrine molecules such as transforming growth factor-beta (TGF-beta) and platelet derived growth factors (PDGFs) that aid tumor growth, local invasion, and development of metastases. The hard, fibrotic shell of desmoplasia serves as a barrier to the infiltration of both chemo- and immunotherapy drugs and host immune cells to the tumor. Although there have been recent improvements in chemotherapy and surgical techniques for management of pancreatic cancer, the majority of patients will die from this disease. Therefore, new treatment strategies are clearly needed. CAFs represent an under-explored potential therapeutic target. This paper discusses what we know about the role of CAFs in pancreatic cancer cell growth, invasion, and metastases. Additionally, we present different strategies that are being and could be explored as anti-CAF treatments for pancreatic cancer.
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27
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Lof S, Korrel M, van Hilst J, Alseidi A, Balzano G, Boggi U, Butturini G, Casadei R, Dokmak S, Edwin B, Falconi M, Keck T, Malleo G, de Pastena M, Tomazic A, Wilmink H, Zerbi A, Besselink MG, Abu Hilal M. Impact of Neoadjuvant Therapy in Resected Pancreatic Ductal Adenocarcinoma of the Pancreatic Body or Tail on Surgical and Oncological Outcome: A Propensity-Score Matched Multicenter Study. Ann Surg Oncol 2019; 27:1986-1996. [PMID: 31848815 PMCID: PMC7210228 DOI: 10.1245/s10434-019-08137-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Several studies have suggested a survival benefit of neoadjuvant therapy (NAT) for pancreatic ductal adenocarcinoma (PDAC) in the pancreatic head. Data concerning NAT for PDAC located in pancreatic body or tail are lacking. METHODS Post hoc analysis of an international multicenter retrospective cohort of distal pancreatectomy for PDAC in 34 centers from 11 countries (2007-2015). Patients who underwent resection after NAT were matched (1:1 ratio), using propensity scores based on baseline characteristics, to patients who underwent upfront resection. Median overall survival was compared using the stratified log-rank test. RESULTS Among 1236 patients, 136 (11.0%) received NAT, most frequently FOLFIRINOX (25.7%). In total, 94 patients receiving NAT were matched to 94 patients undergoing upfront resection. NAT was associated with less postoperative major morbidity (Clavien-Dindo ≥ 3a, 10.6% vs. 23.4%, P = 0.020) and pancreatic fistula grade B/C (9.6% vs. 21.3%, P = 0.026). NAT did not improve overall survival [27 (95% CI 14-39) versus 31 months (95% CI 19-42), P = 0.277], as compared with upfront resection. In a sensitivity analysis of 251 patients with radiographic tumor involvement of splenic vessels, NAT (n = 37, 14.7%) was associated with prolonged overall survival [36 (95% CI 18-53) versus 20 months (95% CI 15-24), P = 0.049], as compared with upfront resection. CONCLUSION In this international multicenter cohort study, NAT for resected PDAC in pancreatic body or tail was associated with less morbidity and pancreatic fistula but similar overall survival in comparison with upfront resection. Prospective studies should confirm a survival benefit of NAT in patients with PDAC and splenic vessel involvement.
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Affiliation(s)
- Sanne Lof
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, UK.,Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Maarten Korrel
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jony van Hilst
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Surgery, OLVG, Amsterdam, The Netherlands
| | - Adnan Alseidi
- Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Gianpaolo Balzano
- Pancreatic Surgery, San Raffaele Hospital IRCCS, Università Vita-Salute, Milan, Italy
| | - Ugo Boggi
- Department of Surgery, Universitá di Pisa, Pisa, Italy
| | | | - Riccardo Casadei
- Department of Surgery, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Safi Dokmak
- Department of Surgery, Hospital of Beaujon, Clichy, France
| | - Bjørn Edwin
- Department of Surgery, Oslo University Hospital and Institute for Clinical Medicine, Oslo, Norway
| | - Massimo Falconi
- Pancreatic Surgery, San Raffaele Hospital IRCCS, Università Vita-Salute, Milan, Italy
| | - Tobias Keck
- Clinic for Surgery, UKSH Campus Lübeck, Lübeck, Germany
| | - Giuseppe Malleo
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Matteo de Pastena
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Ales Tomazic
- Department of Surgery, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Hanneke Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Alessandro Zerbi
- Department of Surgery, Humanitas University Hospital, Milan, Italy
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Mohammed Abu Hilal
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, UK. .,Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy.
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