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Barenboim A, Mercer D, Sahnan K, Gaffan A, Goren O, Halperin S, Brazowski E, Pelles Avraham S, Klausner JM, Lubezky N. The Relationship between Treatment Response and Overall Survival in Borderline, Non-Resectable and Resectable Pancreatic Cancer Patients Treated with Neoadjuvant FOLFIRINOX. J Clin Med 2024; 13:5206. [PMID: 39274419 PMCID: PMC11396552 DOI: 10.3390/jcm13175206] [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: 07/28/2024] [Revised: 08/26/2024] [Accepted: 08/30/2024] [Indexed: 09/16/2024] Open
Abstract
Background: The National Comprehensive Cancer Network (NCCN)-recommended treatment for patients with borderline-resectable pancreatic cancer (BRPC) and locally advanced pancreatic cancer (LAPC) involves a combination of neoadjuvant FOLFIRINOX chemotherapy and the curative surgical resection of the tumor. This study seeks to identify the clinical, radiological, laboratory, and pathologic predictors that can anticipate the oncological outcomes of patients. Methods: In this study, we conducted a retrospective analysis of patients who had undergone curative surgical resection for BRPC, LAPC, or resectable disease with high-risk features after receiving neoadjuvant FOLFIRINOX at two institutions. We evaluated by means of multivariate analysis whether clinical and laboratory response, tumor markers, radiological response, and pathologic tumor response grade correlated with overall survival (OS) and disease-free survival (DFS). Results: The study enrolled a total of 70 patients with BRPC, LAPC, and resectable disease with high-risk features who underwent resection after neoadjuvant FOLFIRINOX. Age above 65 years and fewer than nine cycles of chemotherapy (OR 4.2; 95% CI 1.4-12.0; p-value 0.007); locally advanced tumors after neoadjuvant treatment (NAT) (OR 7.0; 95% CI 1.9-25.7; p-value 0.003); and lymph node disease and histological tumor regression grade 2 and 3 (OR 4.3; 95% CI 0.9-19.2; p-value 0.05) were risk factors linked to adverse OS and DFS. The median OS and DFS were 33 (22-43.9) months and 16.5 (11.3-21.6) months, respectively. Conclusions: Classification as a LA tumor after NAT was the only preoperative radiological factor that predicted adverse survival in patients undergoing curative surgery after NAT. Other clinical, biochemical, and radiological measures of response were not found to predict OS. Patient age, the cumulative administration of more than eight cycles of chemotherapy, and a significant pathological response were associated with better OS. The results of this study are important for treatment decision-making and prognostication in patients with BRPC and LAPC.
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Affiliation(s)
- Alex Barenboim
- Department of Surgery, Tel-Aviv Medical Center, Sackler School of Medicine, The Nicholas and Elizabeth Cathedra of Experimental Surgery, Tel Aviv University, Tel-Aviv 6997801, Israel
| | - Diego Mercer
- Department of Radiology, Tel-Aviv Medical Center, Sackler School of Medicine, The Nicholas and Elizabeth Cathedra of Experimental Surgery, Tel Aviv University, Tel-Aviv 6997801, Israel
| | | | - Alex Gaffan
- Department of Surgery, Tel-Aviv Medical Center, Sackler School of Medicine, The Nicholas and Elizabeth Cathedra of Experimental Surgery, Tel Aviv University, Tel-Aviv 6997801, Israel
| | - Or Goren
- Institute of Anesthesiology, Tel-Aviv Medical Center, Sackler School of Medicine, The Nicholas and Elizabeth Cathedra of Experimental Surgery, Tel Aviv University, Tel-Aviv 6997801, Israel
| | - Sharon Halperin
- Institute of Oncology, Sheba Medical Center, Ramat Gan 5262000, Israel
| | - Eli Brazowski
- Institute of Pathology, Tel-Aviv Medical Center, Sackler School of Medicine, The Nicholas and Elizabeth Cathedra of Experimental Surgery, Tel Aviv University, Tel-Aviv 6997801, Israel
| | - Sharon Pelles Avraham
- Institute of Oncology, Tel-Aviv Medical Center, Sackler School of Medicine, The Nicholas and Elizabeth Cathedra of Experimental Surgery, Tel Aviv University, Tel-Aviv 6997801, Israel
| | - Joseph M Klausner
- Department of Surgery, Tel-Aviv Medical Center, Sackler School of Medicine, The Nicholas and Elizabeth Cathedra of Experimental Surgery, Tel Aviv University, Tel-Aviv 6997801, Israel
| | - Nir Lubezky
- Department of HPB and Transplant Surgery, Tel-Aviv Medical Center, Sackler School of Medicine, The Nicholas and Elizabeth Cathedra of Experimental Surgery, Tel Aviv University, Tel-Aviv 6997801, Israel
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Okamura Y, Nishitai R, Sasaki N, Ito H, Sakamoto T, Itokawa Y, Kusumoto M, Nakai Y, Yamaoka T, Manaka D. Neoadjuvant therapy with intensity-modulated radiotherapy combined with S-1 for borderline-resectable pancreatic cancer. Asia Pac J Clin Oncol 2024; 20:546-554. [PMID: 38771310 DOI: 10.1111/ajco.14080] [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: 09/21/2023] [Revised: 03/23/2024] [Accepted: 05/07/2024] [Indexed: 05/22/2024]
Abstract
AIM We evaluated the efficacy of neoadjuvant chemotherapy with intensity-modulated radiotherapy (NAC-IMRT) in patients with borderline-resectable pancreatic cancer (BRPC). METHODS BRPC patients were treated with IMRT (45 Gy/15fr) combined with two courses of S-1 (40 mg/m2 bid) before surgery. Outcomes after NAC-IMRT, surgery, and survival were then evaluated. This single-center retrospective study assessed 26 consecutive patients. RESULTS Twenty-six patients (BR-PV: 7, BR-A: 19) with a median age of 73 years were enrolled from 2016 to 2021. Ten (38%) patients were 75-years-old and above. Twenty-three patients completed NAC-IMRT treatment. The median reductions in tumor size and cancer antigen 19-9 level were 13.6% and 69%, respectively. All 26 patients underwent resection within a median time of 71 days after NAC-IMRT initiation. R0 resection was achieved in 24 patients (92%). The median overall survival (OS) was 28.0 months, and the 1- and 3-year OS rates were 100% and 34%, respectively. The median progression-free survival (PFS) was 12.5 months, and the 1- and 3-year PFS rates were 50% and 32%, respectively. No significant differences were observed in OS between the patients under and over the age of 75 (29 vs. 20 months, p = 0.86). The 12 patients who completed NAC-IMRT, resection, and subsequent adjuvant chemotherapy (AC) exhibited a 3-year survival rate of 73%, which was significantly better than that of the patients who did not receive or complete AC (median OS, not reached vs. 19 months, p < 0.001). CONCLUSION NAC-IMRT showed outstanding clinical efficacy with acceptable tolerability in patients with BRPC, including geriatric patients.
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Affiliation(s)
- Yusuke Okamura
- Department of Surgery, Kyoto Katsura Hospital, Kyoto, Japan
| | - Ryuta Nishitai
- Department of Surgery, Kyoto Katsura Hospital, Kyoto, Japan
| | - Naoya Sasaki
- Department of Surgery, Kyoto Katsura Hospital, Kyoto, Japan
| | - Hitoshi Ito
- Department of Radiation Oncology, Kyoto Katsura Hospital, Kyoto, Japan
| | - Takashi Sakamoto
- Department of Radiation Oncology, Kyoto Katsura Hospital, Kyoto, Japan
| | - Yoshio Itokawa
- Department of Gastroenterological Medicine, Kyoto Katsura Hospital, Kyoto, Japan
| | - Masanori Kusumoto
- Department of Gastroenterological Medicine, Kyoto Katsura Hospital, Kyoto, Japan
| | - Yoshitaka Nakai
- Department of Gastroenterological Medicine, Kyoto Katsura Hospital, Kyoto, Japan
| | - Toshihide Yamaoka
- Department of Diagnostic Imaging and Interventional Radiology, Kyoto Katsura Hospital, Kyoto, Japan
| | - Dai Manaka
- Department of Surgery, Kyoto Katsura Hospital, Kyoto, Japan
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Wu HY, Li JW, Li JZ, Zhai QL, Ye JY, Zheng SY, Fang K. Comprehensive multimodal management of borderline resectable pancreatic cancer: Current status and progress. World J Gastrointest Surg 2023; 15:142-162. [PMID: 36896309 PMCID: PMC9988647 DOI: 10.4240/wjgs.v15.i2.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/23/2022] [Accepted: 01/12/2023] [Indexed: 02/27/2023] Open
Abstract
Borderline resectable pancreatic cancer (BRPC) is a complex clinical entity with specific biological features. Criteria for resectability need to be assessed in combination with tumor anatomy and oncology. Neoadjuvant therapy (NAT) for BRPC patients is associated with additional survival benefits. Research is currently focused on exploring the optimal NAT regimen and more reliable ways of assessing response to NAT. More attention to management standards during NAT, including biliary drainage and nutritional support, is needed. Surgery remains the cornerstone of BRPC treatment and multidisciplinary teams can help to evaluate whether patients are suitable for surgery and provide individualized management during the perioperative period, including NAT responsiveness and the selection of surgical timing.
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Affiliation(s)
- Hong-Yu Wu
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Jin-Wei Li
- Department of Neurosurgery, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou 545000, Guangxi Province, China
| | - Jin-Zheng Li
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Qi-Long Zhai
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Jing-Yuan Ye
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Si-Yuan Zheng
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Kun Fang
- Department of Surgery, Yinchuan Maternal and Child Health Hospital, Yinchuan 750000, Ningxia, China
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Nappo G, Donisi G, Zerbi A. Borderline resectable pancreatic cancer: Certainties and controversies. World J Gastrointest Surg 2021; 13:516-528. [PMID: 34194610 PMCID: PMC8223708 DOI: 10.4240/wjgs.v13.i6.516] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/09/2021] [Accepted: 05/25/2021] [Indexed: 02/06/2023] Open
Abstract
Borderline resectable (BR) pancreatic ductal adenocarcinoma (PDAC) is currently a well-recognized entity, characterized by some specific anatomic, biological and conditional features: It includes patients with a stage of disease intermediate between the resectable and the locally advanced ones. The term BR identifies a tumour with an aggressive biological behaviour, on which a neoadjuvant approach instead of an upfront surgery one should be preferred, in order to obtain a radical resection (R0) and to avoid an early recurrence after surgery. Even if during the last decades several studies on this topic have been published, some aspects of BR-PDAC still represent a matter of debate. The aim of this review is to critically analyse the available literature on this topic, particularly focusing on: The problem of the heterogeneity of definition of BR-PDAC adopted, leading to a misinterpretation of published data; its current management (neoadjuvant vs upfront surgery); which neoadjuvant regimen should be preferably adopted; the problem of radiological restaging and the determination of resectability after neoadjuvant therapy; the post-operative outcomes after surgery; and the role and efficacy of adjuvant treatment for resected patients that already underwent neoadjuvant therapy.
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Affiliation(s)
- Gennaro Nappo
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center-IRCCS, Rozzano 20089, Italy
| | - Greta Donisi
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center-IRCCS, Rozzano 20089, Italy
| | - Alessandro Zerbi
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center-IRCCS, Rozzano 20089, Italy
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Jeon SK, Lee JM, Lee ES, Yu MH, Joo I, Yoon JH, Jang JY, Lee KB, Lee SH. How to approach pancreatic cancer after neoadjuvant treatment: assessment of resectability using multidetector CT and tumor markers. Eur Radiol 2021; 32:56-66. [PMID: 34170366 DOI: 10.1007/s00330-021-08108-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 04/29/2021] [Accepted: 05/28/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To investigate clinical and CT factors associated with local resectability in patients with nonmetastatic pancreatic cancers after neoadjuvant chemotherapy ± radiation therapy (CRT). METHODS This retrospective study included consecutive patients with nonmetastatic pancreatic cancers who underwent neoadjuvant CRT between June 2009 and June 2019. Tumor size, tumor-vascular contact with artery/vein, and local resectability categories (resectable, borderline resectable, or locally advanced) were assessed at baseline and post-CRT CT. Baseline and post-CRT carbohydrate antigen (CA) 19-9 levels were also assessed. Clinical or imaging features related to R0 resection were determined using logistic regression analysis. RESULTS A total of 179 patients (mean age, 62.4 ± 9.3 years; 92 men) were included. After neoadjuvant CRT, 105 (58.7%) patients received R0 resection, while 74 (41.3%) did not. R0 resection rates were significantly different according to post-CRT CT resectability categories (p < 0.001): 82.8% (48/58), 70.1% (47/67), and 18.5% (10/54) for resectable, borderline resectable, and locally advanced disease, respectively. For post-CRT borderline resectable disease, ≥ 50% decrease in CA 19-9 was significantly associated with R0 resection (odds ratio (OR), 3.160; p = 0.02). For post-CRT locally advanced disease, small post-CRT tumor size ≤ 2 cm (OR, 9.668; p = 0.026) and decreased tumor-arterial contact (OR, 24.213; p = 0.022) were significantly associated with R0 resection. CONCLUSION Post-CRT CT resectability categorization may be useful for the assessment of R0 resectability in patients with pancreatic cancer following neoadjuvant CRT. Additionally, ≥ 50% decrease in CA 19-9 was associated with R0 resection in post-CRT borderline resectable disease, while small post-CRT tumor size and decreased tumor-arterial contact were with locally advanced disease. KEY POINTS • R0 resection rates following neoadjuvant chemotherapy ± radiation therapy (CRT) were 82.8%, 70.1%, and 18.5% in resectable, borderline resectable, and locally advanced disease, respectively, at post-CRT CT (p < 0.001). • For post-CRT borderline resectable disease, ≥ 50% decrease in carbohydrate antigen (CA) 19-9 was significantly associated with R0 resection. • For post-CRT locally advanced disease, small post-CRT tumor size ≤ 2 cm and decreased tumor-arterial contact were significantly associated with R0 resection.
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Affiliation(s)
- Sun Kyung Jeon
- Department of Radiology, Seoul National University Hospital and Seoul National University College of Medicine, 101 Daehangno, Jongno-gu, Seoul, 03080, South Korea
| | - Jeong Min Lee
- Department of Radiology, Seoul National University Hospital and Seoul National University College of Medicine, 101 Daehangno, Jongno-gu, Seoul, 03080, South Korea.
| | - Eun Sun Lee
- Department of Radiology, Chung-Ang University Hospital, Seoul, South Korea
| | - Mi Hye Yu
- Department of Radiology, Konkuk University Hospital, Seoul, South Korea
| | - Ijin Joo
- Department of Radiology, Seoul National University Hospital and Seoul National University College of Medicine, 101 Daehangno, Jongno-gu, Seoul, 03080, South Korea
| | - Jeong Hee Yoon
- Department of Radiology, Seoul National University Hospital and Seoul National University College of Medicine, 101 Daehangno, Jongno-gu, Seoul, 03080, South Korea
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul, South Korea
| | - Kyoung Bun Lee
- Department of Pathology, Seoul National University Hospital, Seoul, South Korea
| | - Sang Hyup Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
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