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Keltner S, Nelson B, Kharofa J. Indications for Radiation in Pancreatic Adenocarcinoma: A Review. Surg Clin North Am 2024; 104:1007-1016. [PMID: 39237160 DOI: 10.1016/j.suc.2024.05.003] [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: 09/07/2024]
Abstract
Pancreatic adenocarcinoma remains a deadly disease with 5 year overall survival of 10% among all stages. Standard of care for resectable disease remains surgical resection and adjuvant systemic therapy, but paradigms for borderline resectable and unresectable cases remain more nuanced. Radiation has been explored in the neoadjuvant, adjuvant, and definitive settings in a variety of randomized and non-randomized trials with mixed results. There is strong evidence to support the use of neoadjuvant radiation for borderline resectable pancreatic cancer. Utilization of radiation in the adjuvant setting remains unclear while the results of radiation therapy oncology group (RTOG) 0848 are pending.
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Affiliation(s)
- Samuel Keltner
- Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Bailey Nelson
- Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jordan Kharofa
- Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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Amhis N, Carignan J, Tai LH. Transforming pancreaticobiliary cancer treatment: Exploring the frontiers of adoptive cell therapy and cancer vaccines. MOLECULAR THERAPY. ONCOLOGY 2024; 32:200825. [PMID: 39006944 PMCID: PMC11246060 DOI: 10.1016/j.omton.2024.200825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Abstract
Pancreaticobiliary cancer, encompassing malignancies of both the pancreatic and biliary tract, presents a formidable clinical challenge marked by a uniformly bleak prognosis. The asymptomatic nature of its early stages often leads to delayed detection, contributing to an unfavorable 5-year overall survival rate. Conventional treatment modalities have shown limited efficacy, underscoring the urgent need for alternative therapeutic approaches. In recent years, immunotherapy has emerged as a promising avenue in the fight against pancreaticobiliary cancer. Strategies such as therapeutic vaccines and the use of tumor-infiltrating lymphocytes have garnered attention for their potential to elicit more robust and durable responses. This review seeks to illuminate the landscape of emerging immunotherapeutic interventions, offering insights from both clinical and research perspectives. By deepening our understanding of pancreaticobiliary cancer and exploring innovative treatment modalities, we aim to catalyze improvements in patient outcomes and quality of life.
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Affiliation(s)
- Nawal Amhis
- Department of Immunology and Cell Biology, Université de Sherbrooke, Sherbrooke, QC J1E 4K8, Canada
- Department of Surgery, Division of General Surgery, Université de Sherbrooke, Sherbrooke, QC J1H 5N4, Canada
| | - Julie Carignan
- Centre de Recherche du CHUS, Sherbrooke, QC J1H 5N4, Canada
| | - Lee-Hwa Tai
- Department of Immunology and Cell Biology, Université de Sherbrooke, Sherbrooke, QC J1E 4K8, Canada
- Centre de Recherche du CHUS, Sherbrooke, QC J1H 5N4, Canada
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van 't Land FR, Willemsen M, Bezemer K, van der Burg SH, van den Bosch TPP, Doukas M, Fellah A, Kolijn PM, Langerak AW, Moskie M, van der Oost E, Rozendaal NEM, Baart SJ, Aerts JGJV, van Eijck CHJ. Dendritic Cell-Based Immunotherapy in Patients With Resected Pancreatic Cancer. J Clin Oncol 2024; 42:3083-3093. [PMID: 38950309 PMCID: PMC11379361 DOI: 10.1200/jco.23.02585] [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: 11/30/2023] [Revised: 03/04/2024] [Accepted: 04/16/2024] [Indexed: 07/03/2024] Open
Abstract
PURPOSE Immunotherapies have shown limited responses in patients with advanced pancreatic cancer. Recently, we reported that dendritic cell (DC)-based immunotherapy induced T-cell responses against pancreatic cancer antigens. The primary objective of this study was to determine the efficacy of DC-based immunotherapy to prevent recurrence of disease. METHODS This was a single-center, open-label, single-arm, combined phase I/II trial. The primary end point was the 2-year recurrence-free survival (RFS) rate. A 2-year RFS rate of ≥60% was defined as a clinically meaningful improvement. We included patients with pancreatic cancer after resection and completion of standard-of-care (SOC) treatment without recurrent disease on cross-sectional imaging. Patients were treated with autologous DCs pulsed with an allogeneic mesothelioma tumor cell lysate, comprising antigens also expressed in pancreatic ductal adenocarcinoma. RESULTS Thirty-eight patients were included in the analysis of the primary end point (47% male, 53% female). The median age was 62 years (IQR, 55-68). Twenty-eight patients (74%) received five DC vaccinations and completed the study protocol. Three patients (8%) received four vaccinations, and seven patients (16%) received three vaccinations. After a median follow-up of 25.5 months, 26 patients (68%) had not developed recurrence of disease. The estimated 2-year RFS was 64%. Vaccination led to the enrichment of circulating activated CD4+ T cells and the detection of treatment-induced immune responses in vitro. T-cell receptor-sequencing analyses of a resected solitary lung metastasis showed influx of vaccine-specific T cells. CONCLUSION This study reached its primary end point of a 2-year RFS rate of ≥60% following pancreatectomy after SOC treatment and adjuvant DC-based immunotherapy in patients with pancreatic cancer. These results warrant a future randomized trial.
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Affiliation(s)
- Freek R van 't Land
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
- Department of Pulmonary Medicine, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Marcella Willemsen
- Department of Pulmonary Medicine, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Koen Bezemer
- Department of Pulmonary Medicine, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
- Amphera B.V., 'S-Hertogenbosch, the Netherlands
| | - Sjoerd H van der Burg
- Department of Medical Oncology, Oncode Institute, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Michail Doukas
- Department of Pathology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Amine Fellah
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
- Department of Pulmonary Medicine, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - P Martijn Kolijn
- Department of Immunology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Anton W Langerak
- Department of Immunology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Miranda Moskie
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
- Department of Pulmonary Medicine, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Elise van der Oost
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Nina E M Rozendaal
- Department of Pulmonary Medicine, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Sara J Baart
- Department of Pulmonary Medicine, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
- Department of Biostatistics, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Joachim G J V Aerts
- Department of Pulmonary Medicine, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
- Department of Pulmonary Medicine, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
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You K, Lei K, Wang X, Hu R, Zhang H, Xu J, Liu Z. A novel nomogram based on the number of positive lymph nodes can predict the overall survival of patients with pancreatic head cancer after radical surgery. World J Surg Oncol 2024; 22:241. [PMID: 39245733 DOI: 10.1186/s12957-024-03519-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Accepted: 09/01/2024] [Indexed: 09/10/2024] Open
Abstract
BACKGROUND This study aimed to construct a novel nomogram based on the number of positive lymph nodes to predict the overall survival of patients with pancreatic head cancer after radical surgery. MATERIALS AND METHODS 2271 and 973 patients in the SEER Database were included in the development set and validation set, respectively. The primary clinical endpoint was OS (overall survival). Univariate and multivariate Cox regression analyses were used to screen independent risk factors of OS, and then independent risk factors were used to construct a novel nomogram. The C-index, calibration curves, and decision analysis curves were used to evaluate the predictive power of the nomogram in the development and validation sets. RESULTS After multivariate Cox regression analysis, the independent risk factors for OS included age, tumor extent, chemotherapy, tumor size, LN (lymph nodes) examined, and LN positive. A nomogram was constructed by using independent risk factors for OS. The C-index of the nomogram for OS was 0.652 [(95% confidence interval (CI): 0.639-0.666)] and 0.661 (95%CI: 0.641-0.680) in the development and validation sets, respectively. The calibration curves and decision analysis curves proved that the nomogram had good predictive ability. CONCLUSIONS The nomogram based on the number of positive LN can effectively predict the overall survival of patients with pancreatic head cancer after surgery.
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Affiliation(s)
- Ke You
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400000, China
| | - Kai Lei
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400000, China
| | - Xingxing Wang
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400000, China
| | - Run Hu
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400000, China
| | - Huizhi Zhang
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400000, China
| | - Jie Xu
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400000, China
| | - Zuojin Liu
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400000, China.
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5
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Lu PW, Lyu HG, Prakash LR, Chiang YJS, Maxwell JE, Snyder RA, Kim MP, Tzeng CWD, Katz MHG, Ikoma N. Effect of surgical approach on early return to intended oncologic therapy after resection for pancreatic ductal adenocarcinoma. Surg Endosc 2024; 38:4986-4995. [PMID: 38987482 DOI: 10.1007/s00464-024-11022-3] [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: 03/08/2024] [Accepted: 06/30/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Although robotic pancreatectomy may facilitate an earlier functional recovery, the impact of a robotic pancreatectomy program during its early experience on the timing of return to intended oncologic therapy (RIOT) after surgery is unknown. METHODS In this retrospective cohort study, we used propensity score matching with a 1:2 ratio to compare patients who underwent robotic or open surgery (distal pancreatectomy or pancreatoduodenectomy) for pancreatic ductal adenocarcinoma (PDAC) during the first 3 years of our robotic pancreatectomy experience (January 2018-December 2021). Generalized estimating equations modeling was used to evaluate the effect of surgical approach on early RIOT, defined as adjuvant chemotherapy initiation within 8 weeks after surgery, and late RIOT, defined as initiation within 12 weeks after surgery. RESULTS The matched cohort included 26 patients who underwent robotic pancreatectomy and 52 patients who underwent open pancreatectomy. Rates of receipt of adjuvant chemotherapy were 96.2% and 78.9%, respectively. Rate of early RIOT in the robotic group (73.1% was higher than that in the open group (44.2%; P = 0.018). In multivariable analysis, a robotic approach was associated with early RIOT (odds ratio, 3.54; 95% confidence interval 1.08-11.62; P = 0.038). Surgical approach did not impact late RIOT (odds ratio, 3.21; 95% confidence interval 0.71-14.38; P = 0.128). CONCLUSIONS Compared with open pancreatectomy, robotic pancreatectomy did not delay RIOT. In fact, odds of early RIOT were increased, which supports the oncological safety of our robotic pancreatectomy program during its implementation.
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Affiliation(s)
- Pamela W Lu
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Heather G Lyu
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Laura R Prakash
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Yi-Ju Sabrina Chiang
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Jessica E Maxwell
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Rebecca A Snyder
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Michael P Kim
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA.
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Miller PN, Romero-Hernandez F, Calthorpe L, Wang JJ, Kim SS, Corvera CU, Hirose K, Kirkwood KS, Hirose R, Maker AV, Alseidi AA, Adam MA, Kim GE, Tempero MA, Ko AH, Nakakura EK. Long-Duration Neoadjuvant Therapy with FOLFIRINOX Yields Favorable Outcomes for Patients Who Undergo Surgery for Pancreatic Cancer. Ann Surg Oncol 2024; 31:6147-6156. [PMID: 38879670 PMCID: PMC11300478 DOI: 10.1245/s10434-024-15579-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 05/23/2024] [Indexed: 08/09/2024]
Abstract
BACKGROUND In 2023 alone, it's estimated that over 64,000 patients will be diagnosed with PDAC and more than 50,000 patients will die of the disease. Current guidelines recommend neoadjuvant therapy for patients with borderline resectable and locally advanced PDAC, and data is emerging on its role in resectable disease. Neoadjuvant chemotherapy may increase the number of patients able to receive complete chemotherapy regimens, increase the rate of microscopically tumor-free resection (R0) margin, and aide in identifying unfavorable tumor biology. To date, this is the largest study to examine surgical outcomes after long-duration neoadjuvant chemotherapy for PDAC. METHODS Retrospective analysis of single-institution data. RESULTS The routine use of long-duration therapy in our study (median cycles: FOLFIRINOX = 10; gemcitabine-based = 7) is unique. The majority (85%) of patients received FOLFIRINOX without radiation therapy; the R0 resection rate was 76%. Median OS was 41 months and did not differ significantly among patients with resectable, borderline-resectable, or locally advanced disease. CONCLUSIONS This study demonstrates that in patients who undergo surgical resection after receipt of long-duration neoadjuvant FOLFIRINOX therapy alone, survival outcomes are similar regardless of pretreatment resectability status and that favorable surgical outcomes can be attained.
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Affiliation(s)
- Phoebe N Miller
- Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, University of California, San Francisco, San Francisco, CA, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
- Division of General Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Fernanda Romero-Hernandez
- Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, University of California, San Francisco, San Francisco, CA, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| | - Lucia Calthorpe
- Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, University of California, San Francisco, San Francisco, CA, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| | - Jaeyun Jane Wang
- Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, University of California, San Francisco, San Francisco, CA, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| | - Sunhee S Kim
- Department of Surgery, St. Elizabeth's Medical Center, Boston, MA, USA
| | - Carlos U Corvera
- Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, University of California, San Francisco, San Francisco, CA, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| | - Kenzo Hirose
- Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, University of California, San Francisco, San Francisco, CA, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| | - Kimberly S Kirkwood
- Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, University of California, San Francisco, San Francisco, CA, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| | - Ryutaro Hirose
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Ajay V Maker
- Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, University of California, San Francisco, San Francisco, CA, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| | - Adnan A Alseidi
- Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, University of California, San Francisco, San Francisco, CA, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| | - Mohamed A Adam
- Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, University of California, San Francisco, San Francisco, CA, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| | - Grace E Kim
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
- Department of Pathology, University of California, San Francisco, San Francisco, CA, USA
| | - Margaret A Tempero
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Andrew H Ko
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Eric K Nakakura
- Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, University of California, San Francisco, San Francisco, CA, USA.
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA.
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Yee EJ, Torphy RJ, Thielen ON, Easwaran L, Franklin O, Sugawara T, Bartsch C, Garduno N, McCarter MM, Ahrendt SA, Schulick RD, Del Chiaro M. Radiologic Occult Metastases in Pancreatic Cancer: Analysis of Risk Factors and Survival Outcomes in the Age of Contemporary Neoadjuvant Multi-agent Chemotherapy. Ann Surg Oncol 2024; 31:6127-6137. [PMID: 38780693 DOI: 10.1245/s10434-024-15443-1] [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: 11/16/2023] [Accepted: 04/25/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Radiologic occult metastatic disease (ROMD) in patients with pancreatic ductal adenocarcinoma (PDAC) who undergo contemporary neoadjuvant chemotherapy (NAC) has not been well studied. This study sought to analyze the incidence, risk factors, and oncologic outcomes for patients who underwent the NAC approach for PDAC. METHODS A retrospective review analyzed a prospectively maintained database of patients who had potentially resectable PDAC treated with NAC and were offered pancreatectomy at our institution from 2011 to 2022. Multivariable regression analysis was performed to assess risk factors associated with ROMD. Kaplan-Meier curves with log-rank analyses were generated to estimate time-to-event end points. RESULTS The study enrolled 366 patients. Upfront and borderline resectable anatomic staging comprised 80% of the cohort, whereas 20% had locally advanced disease. The most common NAC regimen was FOLFIRINOX (n = 274, 75%). For 55 patients (15%) who harbored ROMD, the most common site was liver-only metastases (n = 33, 60%). The independent risk factors for ROMD were increasing CA19-9 levels during NAC (odds ratio [OR], 7.01; confidence interval [CI], 1.97-24.96; p = 0.008), indeterminate liver lesions (OR, 2.19; CI, 1.09-4.39; p = 0.028), and enlarged para-aortic lymph nodes (OR, 6.87; CI, 2.07-22.74; p = 0.002) on preoperative cross-sectional imaging. Receipt of palliative chemotherapy (p < 0.001) and eventual formal pancreatectomy (p = 0.04) were associated with survival benefit in the log-rank analysis. The median overall survival (OS) of the patients with ROMD was nearly 15 months from the initial diagnosis, with radiologic evidence of metastases occurring after a median of 2 months. CONCLUSIONS Radiologic occult metastatic disease remains a clinical challenge associated with poor outcomes for patients who have PDAC treated with multi-agent NAC.
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Affiliation(s)
- Elliott J Yee
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert J Torphy
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Otto N Thielen
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Lavanya Easwaran
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Oskar Franklin
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Toshitaka Sugawara
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Christan Bartsch
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Nicole Garduno
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Martin M McCarter
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Steven A Ahrendt
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Richard D Schulick
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Marco Del Chiaro
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, CO, USA.
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Hidaka Y, Tanoue S, Ayukawa T, Takumi K, Noguchi H, Higashi M, Idichi T, Kawasaki Y, Kurahara H, Mataki Y, Ohtsuka T, Koriyama C. Impact of pancreatic ductal occlusion on postoperative outcomes in pancreatic head cancer patients undergoing neoadjuvant therapy. J Gastroenterol 2024; 59:858-868. [PMID: 38900299 PMCID: PMC11338973 DOI: 10.1007/s00535-024-02125-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 06/04/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Pancreatic ductal occlusion can accompany pancreatic head cancer, leading to pancreatic exocrine insufficiency (PEI) and adverse effects on nutritional status and postoperative outcomes. We investigated its impact on nutritional status, body composition, and postoperative outcomes in patients with pancreatic head cancer undergoing neoadjuvant therapy (NAT). METHODS We analyzed 136 patients with pancreatic head cancer who underwent NAT prior to intended pancreaticoduodenectomy (PD) between 2015 and 2022. Nutritional and anthropometric indices (body mass index [BMI], albumin, prognostic nutritional index [PNI], Glasgow prognostic score, psoas muscle index, subcutaneous adipose tissue index [SATI], and visceral adipose tissue index) and postoperative outcomes were compared between the occlusion (n = 78) and non-occlusion (n = 58) groups, in which 61 and 44 patients, respectively, ultimately underwent PD. RESULTS The occlusion group showed significantly lower post-NAT BMI, PNI, and SATI (p = 0.011, 0.005, and 0.015, respectively) in the PD cohort. The occlusion group showed significantly larger main pancreatic duct, smaller pancreatic parenchyma, and greater duct-parenchymal ratio (p < 0.001), and these morphological parameters significantly correlating with post-NAT nutritional and anthropometric indices. Postoperative 3-year survival and recurrence-free survival (RFS) rates were significantly poorer (p = 0.004 and 0.013) with pancreatic ductal occlusion, also identified as an independent postoperative risk factor for overall survival (hazard ratio [HR]: 2.31, 95% confidence interval [CI] 1.08-4.94, p = 0.030) and RFS (HR: 2.03, 95% CI 1.10-3.72, p = 0.023), in multivariate analysis. CONCLUSIONS Pancreatic ductal occlusion may be linked to poorer postoperative outcomes due to PEI-related malnutrition.
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Affiliation(s)
- Yoshifumi Hidaka
- Department of Epidemiology and Preventive Medicine, Graduate School of Medical and Dental Science, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8544, Japan
- Department of Digestive Surgery, Graduate School of Medical and Dental Science, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8544, Japan
| | - Shiroh Tanoue
- Department of Epidemiology and Preventive Medicine, Graduate School of Medical and Dental Science, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8544, Japan.
| | - Takuro Ayukawa
- Department of Radiology, Graduate School of Medical and Dental Science, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8544, Japan
| | - Koji Takumi
- Department of Radiology, Graduate School of Medical and Dental Science, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8544, Japan
| | - Hirotsugu Noguchi
- Department of Pathology, Graduate School of Medical and Dental Science, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8544, Japan
| | - Michiyo Higashi
- Department of Pathology, Graduate School of Medical and Dental Science, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8544, Japan
| | - Tetsuya Idichi
- Department of Digestive Surgery, Graduate School of Medical and Dental Science, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8544, Japan
| | - Yota Kawasaki
- Department of Digestive Surgery, Graduate School of Medical and Dental Science, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8544, Japan
| | - Hiroshi Kurahara
- Department of Digestive Surgery, Graduate School of Medical and Dental Science, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8544, Japan
| | - Yuko Mataki
- Department of Digestive Surgery, Graduate School of Medical and Dental Science, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8544, Japan
| | - Takao Ohtsuka
- Department of Digestive Surgery, Graduate School of Medical and Dental Science, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8544, Japan
| | - Chihaya Koriyama
- Department of Epidemiology and Preventive Medicine, Graduate School of Medical and Dental Science, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8544, Japan
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Lee A, Pasetsky J, Lavrova E, Wang YF, Sedor G, Li FL, Gallitto M, Garrett M, Elliston C, Price M, Kachnic LA, Horowitz DP. CT-guided online adaptive stereotactic body radiotherapy for pancreas ductal adenocarcinoma: Dosimetric and initial clinical experience. Clin Transl Radiat Oncol 2024; 48:100813. [PMID: 39149753 PMCID: PMC11324999 DOI: 10.1016/j.ctro.2024.100813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 05/28/2024] [Accepted: 06/29/2024] [Indexed: 08/17/2024] Open
Abstract
Purpose/Objectives Retrospective analysis suggests that dose escalation to a biologically effective dose of more than 70 Gy may improve overall survival in patients with pancreatic ductal adenocarcinoma (PDAC), but such treatments in practice are limited by proximity of organs at risk (OARs). We hypothesized that CT-guided online adaptive radiotherapy (OART) can account for interfraction movement of OARs and allow for safe delivery of ablative doses. Materials/Methods This is a single institution retrospective analysis of patients with PDAC treated with OART on the Ethos platform (Varian Medical Systems, a Siemens Healthineers Company, Palo Alto). All patients were treated to 40 Gy in 5 fractions. PTV overlapping with a 5 mm planning risk volume expansion on the stomach, duodenum and bowel received 25 Gy. Initial treatment plans were created conventionally. For each fraction, PTV and OAR volumes were recontoured with AI assistance after initial cone beam CT (CBCT). The adapted plan was calculated, underwent QA, and then compared to the scheduled plan. A second CBCT was obtained prior to delivery of the selected plan. Total treatment time (first CBCT to end of radiation delivery) and active physician time (first to second CBCT) were recorded. PTV_4000 V95 %, PTV_2500 V9 5%, and D0.03 cc to stomach, duodenum and bowel were reported for scheduled (S) and adapted (A) plans. CTCAEv5.0 toxicities were recorded. Statistical analysis was performed using a two-sided T test and α of 0.05. Results 21 patients with unresectable or locally-recurrent PDAC were analyzed, with a total of 105 fractions. Average total time was 29 min and 16 s (16:36-49:40) and average active physician time was 19:41 min (9:25-39:34). All fractions were treated with adapted plans. 97 % of adapted plans met PTV_4000 V95.0 % >95.0 % coverage goal and 100 % of adapted plans met OAR dose constraints. Median follow up was 6.6 months. Only 1 patient experienced acute grade 3+ toxicity directly attributable to radiation. Only 1 patient experienced late grade 3+ toxicity directly attributable to radiation. Conclusions Daily CT-based OART was associated with significantly reduced dose OARs while achieving superior PTV coverage. Given the relatively quick total treatment time, radiation delivery was generally well tolerated and easily incorporated into the clinic workflow. Our initial clinical experience demonstrates OART allows for safe dose escalation in the treatment of PDAC.
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Affiliation(s)
- Albert Lee
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY, United States
- Herbert Irving Comprehensive Cancer Center Minority Underserved NCORP, New York, NY, United States
| | - Jared Pasetsky
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY, United States
- Herbert Irving Comprehensive Cancer Center Minority Underserved NCORP, New York, NY, United States
| | - Elizaveta Lavrova
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY, United States
| | - Yi-Fang Wang
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY, United States
| | - Geoffrey Sedor
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY, United States
- Herbert Irving Comprehensive Cancer Center Minority Underserved NCORP, New York, NY, United States
| | - Feng L Li
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY, United States
| | - Matthew Gallitto
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY, United States
- Herbert Irving Comprehensive Cancer Center Minority Underserved NCORP, New York, NY, United States
| | - Matthew Garrett
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY, United States
| | - Carl Elliston
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY, United States
| | - Michael Price
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY, United States
| | - Lisa A Kachnic
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY, United States
- Herbert Irving Comprehensive Cancer Center Minority Underserved NCORP, New York, NY, United States
| | - David P Horowitz
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY, United States
- Herbert Irving Comprehensive Cancer Center Minority Underserved NCORP, New York, NY, United States
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10
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Hall LA, Loader D, Gouveia S, Burak M, Halle-Smith J, Labib P, Alarabiyat M, Marudanayagam R, Dasari BV, Roberts KJ, Raza SS, Papamichail M, Bartlett DC, Sutcliffe RP, Chatzizacharias NA. Management of distal cholangiocarcinoma with arterial involvement: Systematic review and case series on the role of neoadjuvant therapy. World J Gastrointest Surg 2024; 16:2689-2701. [PMID: 39220089 PMCID: PMC11362928 DOI: 10.4240/wjgs.v16.i8.2689] [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: 03/15/2024] [Revised: 05/28/2024] [Accepted: 06/27/2024] [Indexed: 08/16/2024] Open
Abstract
BACKGROUND The use of neoadjuvant therapy (NAT) in distal cholangiocarcinoma (dCCA) with regional arterial or extensive venous involvement, is not widely accepted and evidence is sparse. AIM To synthesise evidence on NAT for dCCA and present the experience of a high-volume tertiary-centre managing dCCA with arterial involvement. METHODS A systematic review was performed according to PRISMA guidance to identify all studies reporting outcomes of patients with dCCA who received NAT. All patients from 2017 to 2022 who were referred for NAT for dCCA at our centre were retrospectively collected from a prospectively maintained database. Baseline characteristics, NAT type, progression to surgery and oncological outcomes were collected. RESULTS Twelve studies were included. The definition of "unresectable" locally advanced dCCA was heterogenous. Four studies reported outcomes for 9 patients who received NAT for dCCA with extensive vascular involvement. R0 resection rate ranged between 0 and 100% but without survival benefit in most cases. Remaining studies considered either NAT in resectable dCCA or inclusive with extrahepatic CCA. The presented case series includes 9 patients (median age 67, IQR 56-74 years, male:female 5:4) referred for NAT for borderline resectable or locally advanced disease. Three patients progressed to surgery and 2 were resected. One patient died at 14 months with evidence of recurrence at 6 months and the other died at 51 months following recurrence 6 months post-operatively. CONCLUSION Evidence for benefit of NAT is limited. Consensus on criteria for uniform definition of resectability for dCCA is required. We propose using the established National-Comprehensive-Cancer-Network® criteria for pancreatic ductal adenocarcinoma.
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Affiliation(s)
- Lewis A Hall
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, United Kingdom
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - Duncan Loader
- College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - Santiago Gouveia
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, United Kingdom
| | - Marta Burak
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, United Kingdom
| | - James Halle-Smith
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, United Kingdom
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - Peter Labib
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, United Kingdom
| | - Moath Alarabiyat
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, United Kingdom
| | - Ravi Marudanayagam
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, United Kingdom
| | - Bobby V Dasari
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, United Kingdom
| | - Keith J Roberts
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, United Kingdom
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - Syed S Raza
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, United Kingdom
| | - Michail Papamichail
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, United Kingdom
| | - David C Bartlett
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, United Kingdom
| | - Robert P Sutcliffe
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, United Kingdom
| | - Nikolaos A Chatzizacharias
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, United Kingdom
- Institute of Clinical Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom
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11
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Nakamura K, Nakagawa M, Ariga M, Higashiguchi T, Chikaishi Y, Matsuo K, Nishijima A, Endo T, Kikuchi K, Morohara K, Katsuno H, Tachi Y, Uyama I, Suda K, Morise Z. Successful pancreatectomy after conversion-intended chemotherapy using gemcitabine and nab-paclitaxel for unresectable adenosquamous carcinoma of the pancreas: a case report. Surg Case Rep 2024; 10:189. [PMID: 39150596 PMCID: PMC11329478 DOI: 10.1186/s40792-024-01989-5] [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: 06/18/2024] [Accepted: 08/05/2024] [Indexed: 08/17/2024] Open
Abstract
BACKGROUND Adenosquamous carcinoma of the pancreas (ASCP) accounts for only 1-4% of all pancreatic exocrine cancers and has a particularly poor prognosis. The efficacy of chemotherapy for ASCP remains unknown because of the small number of cases, and few studies have evaluated conversion-intended chemotherapy. CASE PRESENTATION A 76-year-old woman was referred to our hospital because of epigastric pain and nausea. A preoperative contrast-enhanced multidetector row computed tomography (MDCT) scan revealed a 17 × 17 mm low-density tumor with an ill-defined margin at the arterial phase in the pancreatic head. The tumor involved the common hepatic artery, left hepatic artery bifurcated from the common hepatic artery, and gastroduodenal artery, and was in contact with the portal vein. Fluorodeoxyglucose-positron emission tomography (FDG-PET) showed an uptake in the pancreatic head but no evidence of distant metastasis. The tumor was diagnosed as an adenocarcinoma of the pancreatic head and staged unresectable because the common and left hepatic arteries were involved. Hence, the patient underwent seven courses of conversion-intended chemotherapy using gemcitabine and nab-paclitaxel for pancreatic ductal adenocarcinoma over 7 months. After chemotherapy, the tumor shrank to 10 × 10 mm on contrast-enhanced MDCT. Consequently, the boundary between the tumor and major vessels of the common and left hepatic arteries and the portal vein became clear, and the involvement of the arteries with the tumor was evaluated to be released. The contact of the tumor to the portal vein also reduced to less than half the circumference of the portal vein. FDG-PET showed decreased accumulation in the tumor. Hence, the tumor was judged resectable, and pancreaticoduodenectomy was performed. The tumor and major blood vessels were easily dissected and R0 resection was achieved. The patient experienced no major complications and was discharged on postoperative day 28. The tumor was revealed as ASCP via pathological examination. The patient is alive and recurrence-free seven months after surgery. This is the first report of successful R0 resection for an initially unresectable ASCP following conversion-intended chemotherapy using gemcitabine and nab-paclitaxel regimen. CONCLUSIONS Conversion-intended chemotherapy using gemcitabine and nab-paclitaxel regimen may be effective for ASCP.
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Affiliation(s)
- Kenichi Nakamura
- Department of Surgery, Fujita Health University Okazaki Medical Center, 1 Azakotanda, Harisaki, Okazaki, Aichi, 444-0827, Japan.
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan.
| | - Mitsuru Nakagawa
- Department of Pathology, Fujita Health University Okazaki Medical Center, 1 Azakotanda, Harisaki, Okazaki, Aichi, 444-0827, Japan
| | - Mizuki Ariga
- Department of Gastroenterology, Fujita Health University Okazaki Medical Center, 1 Azakotanda, Harisaki, Okazaki,, Aichi, 444-0827, Japan
| | - Takahiko Higashiguchi
- Department of Surgery, Fujita Health University Okazaki Medical Center, 1 Azakotanda, Harisaki, Okazaki, Aichi, 444-0827, Japan
| | - Yuko Chikaishi
- Department of Surgery, Fujita Health University Okazaki Medical Center, 1 Azakotanda, Harisaki, Okazaki, Aichi, 444-0827, Japan
| | - Kazuhiro Matsuo
- Department of Surgery, Fujita Health University Okazaki Medical Center, 1 Azakotanda, Harisaki, Okazaki, Aichi, 444-0827, Japan
| | - Aki Nishijima
- Department of Pathology, Fujita Health University Okazaki Medical Center, 1 Azakotanda, Harisaki, Okazaki, Aichi, 444-0827, Japan
| | - Tomoyoshi Endo
- Department of Surgery, Fujita Health University Okazaki Medical Center, 1 Azakotanda, Harisaki, Okazaki, Aichi, 444-0827, Japan
| | - Kenji Kikuchi
- Department of Surgery, Fujita Health University Okazaki Medical Center, 1 Azakotanda, Harisaki, Okazaki, Aichi, 444-0827, Japan
| | - Koji Morohara
- Department of Surgery, Fujita Health University Okazaki Medical Center, 1 Azakotanda, Harisaki, Okazaki, Aichi, 444-0827, Japan
| | - Hidetoshi Katsuno
- Department of Surgery, Fujita Health University Okazaki Medical Center, 1 Azakotanda, Harisaki, Okazaki, Aichi, 444-0827, Japan
| | - Yoshihiko Tachi
- Department of Gastroenterology, Fujita Health University Okazaki Medical Center, 1 Azakotanda, Harisaki, Okazaki,, Aichi, 444-0827, Japan
| | - Ichiro Uyama
- Department of Surgery, Fujita Health University Okazaki Medical Center, 1 Azakotanda, Harisaki, Okazaki, Aichi, 444-0827, Japan
- Department of Advanced Robotic and Endoscopic Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan
| | - Koichi Suda
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan
| | - Zenichi Morise
- Department of Surgery, Fujita Health University Okazaki Medical Center, 1 Azakotanda, Harisaki, Okazaki, Aichi, 444-0827, Japan
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12
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Schouten TJ, van Goor IWJM, Dorland GA, Besselink MG, Bonsing BA, Bosscha K, Brosens LAA, Busch OR, Cirkel GA, van Dam RM, Festen S, Groot Koerkamp B, van der Harst E, de Hingh IHJT, Intven MPW, Kazemier G, Liem MSL, van Lienden KP, Los M, de Meijer VE, Patijn GA, Schreinemakers JMJ, Stommel MWJ, van Tienhoven GJ, Verdonk RC, Verkooijen HM, van Santvoort HC, Molenaar IQ, Daamen LA. The Value of Biological and Conditional Factors for Staging of Patients with Resectable Pancreatic Cancer Undergoing Upfront Resection: A Nationwide Analysis. Ann Surg Oncol 2024; 31:4956-4965. [PMID: 38386198 PMCID: PMC11236903 DOI: 10.1245/s10434-024-15070-w] [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: 08/30/2023] [Accepted: 01/31/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Novel definitions suggest that resectability status for pancreatic ductal adenocarcinoma (PDAC) should be assessed beyond anatomical criteria, considering both biological and conditional factors. This has, however, yet to be validated on a nationwide scale. This study evaluated the prognostic value of biological and conditional factors for staging of patients with resectable PDAC. PATIENTS AND METHODS A nationwide observational cohort study was performed, including all consecutive patients who underwent upfront resection of National Comprehensive Cancer Network resectable PDAC in the Netherlands (2014-2019) with complete information on preoperative carbohydrate antigen (CA) 19-9 and Eastern Cooperative Oncology Group (ECOG) performance status. PDAC was considered biologically unfavorable (RB+) if CA19-9 ≥ 500 U/mL and favorable (RB-) otherwise. ECOG ≥ 2 was considered conditionally unfavorable (RC+) and favorable otherwise (RC-). Overall survival (OS) was assessed using Kaplan-Meier and Cox-proportional hazard analysis, presented as hazard ratios (HRs) with 95% confidence interval (CI). RESULTS Overall, 688 patients were analyzed with a median overall survival (OS) of 20 months (95% CI 19-23). OS was 14 months (95% CI 10 months-median not reached) in 20 RB+C+ patients (3%; HR 1.61, 95% CI 0.86-2.70), 13 months (95% CI 11-15) in 156 RB+C- patients (23%; HR 1.86, 95% CI 1.50-2.31), and 21 months (95% CI 12-41) in 47 RB-C+ patients (7%; HR 1.14, 95% CI 0.80-1.62) compared with 24 months (95% CI 22-27) in 465 patients with RB-C- PDAC (68%; reference). CONCLUSIONS Survival after upfront resection of anatomically resectable PDAC is worse in patients with CA19-9 ≥ 500 U/mL, while performance status had no impact. This supports consideration of CA19-9 in preoperative staging of resectable PDAC.
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Affiliation(s)
- Thijs J Schouten
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands
| | - Iris W J M van Goor
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands
- Department of Radiation Oncology, University Medical Center Utrecht Cancer Center, Utrecht, The Netherlands
| | - Galina A Dorland
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands
| | - Marc G Besselink
- Amsterdam UMC, Department of Surgery, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht Cancer Center, Utrecht, The Netherlands
| | - Olivier R Busch
- Amsterdam UMC, Department of Surgery, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Geert A Cirkel
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
- Department of Medical Oncology, Meander Medical Center, Amersfoort, The Netherlands
| | - Ronald M van Dam
- Department of Surgery, Maastricht UMC+,, Maastricht, The Netherlands
- GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
- Department of General and Visceral Surgery, University Hospital Aachen, Aachen, Germany
| | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | | | - Ignace H J T de Hingh
- GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Martijn P W Intven
- Department of Radiation Oncology, University Medical Center Utrecht Cancer Center, Utrecht, The Netherlands
| | - Geert Kazemier
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Mike S L Liem
- Department of Surgery, Medical Spectrum Twente, Enschede, The Netherlands
| | - Krijn P van Lienden
- Department of Interventional Radiology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - Maartje Los
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala Clinics, Zwolle, The Netherlands
| | | | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Geert Jan van Tienhoven
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Amsterdam UMC, Department of Radiation Oncology, location University of Amsterdam, Amsterdam, The Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - Helena M Verkooijen
- Imaging Division, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands
| | - Lois A Daamen
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands.
- Imaging Division, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
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13
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van Eijck CWF, Vadgama D, van Eijck CHJ, Wilmink JW. Metformin boosts antitumor immunity and improves prognosis in upfront resected pancreatic cancer: an observational study. J Natl Cancer Inst 2024; 116:1374-1383. [PMID: 38530777 PMCID: PMC11308183 DOI: 10.1093/jnci/djae070] [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: 01/09/2024] [Revised: 02/12/2024] [Accepted: 03/04/2024] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND Beyond demographic and immune factors, metabolic considerations, particularly metformin's recognized impact in oncology, warrant exploration in treating pancreatic cancer. This study aimed to investigate the influence of metformin on patient survival and its potential correlation with distinct immune profiles in pancreatic ductal adenocarcinoma (PDAC) tumors. METHODS We included 82 upfront resected and 66 gemcitabine-based neoadjuvant chemoradiotherapy (nCRT)-treated patients from the PREOPANC randomized controlled trial (RCT). Transcriptomic NanoString immunoprofiling was performed for a subset of 96 available resected specimens. RESULTS Disparities in survival outcomes and immune profiles were apparent between metformin and non-metformin users in upfront resected patients but lacking in nCRT-treated patients. Compared to non-metformin users, upfront resected metformin users showed a higher median overall survival (OS) of 29 vs 14 months and a better 5-year OS rate of 19% vs 5%. Furthermore, metformin use was a favorable prognostic factor for OS in the upfront surgery group (HR = 0.56; 95% CI = 0.32 to 0.99). Transcriptomic data revealed that metformin users significantly underexpressed genes related to pro-tumoral immunity, including monocyte to M2 macrophage polarization and activation. Furthermore, the relative abundance of anti-inflammatory CD163+ MRC1+ M2 macrophages in non-metformin users and immune-activating CD1A+ CD1C+ dendritic cells in metformin users was heightened (P < .001). CONCLUSION This study unveils immune profile changes resulting from metformin use in upfront resected pancreatic cancer patients, possibly contributing to prolonged survival outcomes. Specifically, metformin use may decrease the abundance and activity of pro-tumoral M2 macrophages and increase the recruitment and function of tumor-resolving DCs, favoring antitumor immunity.[PREOPANC trial EudraCT: 2012-003181-40].
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Affiliation(s)
- Casper W F van Eijck
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
- Erasmus MC Cancer Institute, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Disha Vadgama
- Erasmus MC Cancer Institute, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Johanna W Wilmink
- Department of Medical Oncology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
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14
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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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15
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Maruo M, Ikeura T, Takaori A, Ikeda M, Nakamaru K, Ito T, Masuda M, Mitsuyama T, Nakayama S, Shimatani M, Takaoka M, Shibata N, Boku S, Yasuda T, Miyazaki H, Matsumura K, Yamaki S, Hashimoto D, Satoi S, Naganuma M. Impact of endoscopic ultrasound-guided tissue acquisition on prognosis and peritoneal lavage cytology in resectable or borderline resectable pancreatic ductal adenocarcinoma. Pancreatology 2024; 24:787-795. [PMID: 38871559 DOI: 10.1016/j.pan.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 05/20/2024] [Accepted: 06/02/2024] [Indexed: 06/15/2024]
Abstract
OBJECTIVES This study aimed to evaluate the clinical impact of preoperative endoscopic ultrasound-guided tissue acquisition (EUS-TA) on the prognosis and incidence of positive peritoneal lavage cytology (PLC) during laparotomy or staging laparoscopy in patients with resectable (R) or borderline resectable (BR) pancreatic ductal adenocarcinoma (PDAC). METHODS We retrospectively collected data from patients diagnosed with body and tail PDAC with/without EUS-TA at our hospital from January 2006 to December 2021. RESULTS To examine the effect of EUS-TA on prognosis, 153 patients (122 in the EUS-TA group, 31 in the non-EUS-TA group) were analyzed. There was no significant difference in overall survival between the EUS-TA and non-EUS-TA groups after PDAC resection (P = 0.777). In univariate and multivariate analysis, preoperative EUS-TA was not identified as an independent factor related to overall survival after pancreatectomy [hazard ratio 0.96, 95 % confidence interval (CI) 0.54-1.70, P = 0.897]. Next, to examine the direct influence of EUS-TA on the results of PLC, 114 patients (83 in the EUS-TA group and 31 in the non-EUS-TA group) were analyzed. Preoperative EUS-TA was not statistically associated with positive PLC (odds ratio 0.73, 95 % CI 0.25-2.20, P = 0.583). After propensity score matching, overall survival and positive PLC were the same in both groups. CONCLUSIONS EUS-TA had no negative impact on postoperative survival and PLC-positive rates in R/BR PDAC.
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Affiliation(s)
- Motonobu Maruo
- Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Tsukasa Ikeura
- Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan.
| | - Ayaka Takaori
- Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Masatoshi Ikeda
- Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Koh Nakamaru
- Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Takashi Ito
- Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Masataka Masuda
- Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Toshiyuki Mitsuyama
- Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Shinji Nakayama
- Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Masaaki Shimatani
- Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Makoto Takaoka
- Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Nobuhiro Shibata
- Cancer Treatment Center, Kansai Medical University, Osaka, Japan
| | - Shogen Boku
- Cancer Treatment Center, Kansai Medical University, Osaka, Japan
| | - Tomoyo Yasuda
- Cancer Treatment Center, Kansai Medical University, Osaka, Japan
| | | | | | - So Yamaki
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | | | - Sohei Satoi
- Department of Surgery, Kansai Medical University, Osaka, Japan; Division of Surgical Oncology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Makoto Naganuma
- Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
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16
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Eade AV, Friedman LR, Larrain C, Rainey A, Hernandez JM, Chawla A, Ferrone CR. ALLIANCE A021806: A Phase III Trial of Perioperative Versus Adjuvant Chemotherapy for Resectable Pancreatic Cancer. Ann Surg Oncol 2024:10.1245/s10434-024-15817-5. [PMID: 39048905 DOI: 10.1245/s10434-024-15817-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Accepted: 06/28/2024] [Indexed: 07/27/2024]
Affiliation(s)
- Alyssa V Eade
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Lindsay R Friedman
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Carolina Larrain
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Ashley Rainey
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jonathan M Hernandez
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA.
| | - Akhil Chawla
- Division of Surgical Oncology, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, USA
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17
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Ferdous KU, Tesfay MZ, Cios A, Shelton RS, Hartupee C, Urbaniak A, Chamcheu JC, Mavros MN, Giorgakis E, Mustafa B, Simoes CC, Miousse IR, Basnakian AG, Moaven O, Post SR, Cannon MJ, Kelly T, Nagalo BM. Enhancing Neoadjuvant Virotherapy's Effectiveness by Targeting Stroma to Improve Resectability in Pancreatic Cancer. Biomedicines 2024; 12:1596. [PMID: 39062169 PMCID: PMC11275208 DOI: 10.3390/biomedicines12071596] [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: 06/24/2024] [Revised: 07/15/2024] [Accepted: 07/16/2024] [Indexed: 07/28/2024] Open
Abstract
About one-fourth of patients with pancreatic ductal adenocarcinoma (PDAC) are categorized as borderline resectable (BR) or locally advanced (LA). Chemotherapy and radiation therapy have not yielded the anticipated outcomes in curing patients with BR/LA PDAC. The surgical resection of these tumors presents challenges owing to the unpredictability of the resection margin, involvement of vasculature with the tumor, the likelihood of occult metastasis, a higher ratio of positive lymph nodes, and the relatively larger size of tumor nodules. Oncolytic virotherapy has shown promising activity in preclinical PDAC models. Unfortunately, the desmoplastic stroma within the PDAC tumor microenvironment establishes a barrier, hindering the infiltration of oncolytic viruses and various therapeutic drugs-such as antibodies, adoptive cell therapy agents, and chemotherapeutic agents-in reaching the tumor site. Recently, a growing emphasis has been placed on targeting major acellular components of tumor stroma, such as hyaluronic acid and collagen, to enhance drug penetration. Oncolytic viruses can be engineered to express proteolytic enzymes that cleave hyaluronic acid and collagen into smaller polypeptides, thereby softening the desmoplastic stroma, ultimately leading to increased viral distribution along with increased oncolysis and subsequent tumor size regression. This approach may offer new possibilities to improve the resectability of patients diagnosed with BR and LA PDAC.
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Affiliation(s)
- Khandoker Usran Ferdous
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (K.U.F.); (M.Z.T.); (A.C.); (C.C.S.); (S.R.P.); (T.K.)
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (M.N.M.); (M.J.C.)
| | - Mulu Z. Tesfay
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (K.U.F.); (M.Z.T.); (A.C.); (C.C.S.); (S.R.P.); (T.K.)
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (M.N.M.); (M.J.C.)
| | - Aleksandra Cios
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (K.U.F.); (M.Z.T.); (A.C.); (C.C.S.); (S.R.P.); (T.K.)
| | - Randal S. Shelton
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA;
| | - Conner Hartupee
- Division of Surgical Oncology, Department of Surgery, Louisiana State University (LSU) Health, New Orleans, LA 70112, USA; (C.H.); (O.M.)
| | - Alicja Urbaniak
- Department of Biochemistry and Molecular Biology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (A.U.); (I.R.M.)
| | - Jean Christopher Chamcheu
- Department of Biological Sciences and Chemistry, Southern University and A&M College, Baton Rouge, LA 70813, USA;
- Division of Biotechnology and Molecular Medicine, Department of Pathobiological Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA 70803, USA
| | - Michail N. Mavros
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (M.N.M.); (M.J.C.)
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA;
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA;
| | - Emmanouil Giorgakis
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA;
| | - Bahaa Mustafa
- Department of Pharmaceutical Sciences, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA;
| | - Camila C. Simoes
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (K.U.F.); (M.Z.T.); (A.C.); (C.C.S.); (S.R.P.); (T.K.)
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (M.N.M.); (M.J.C.)
| | - Isabelle R. Miousse
- Department of Biochemistry and Molecular Biology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (A.U.); (I.R.M.)
| | - Alexei G. Basnakian
- Department of Pharmacology and Toxicology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA;
- Central Arkansas Veterans Healthcare System, John L. McClellan Memorial VA Hospital, Little Rock, AR 72205, USA
| | - Omeed Moaven
- Division of Surgical Oncology, Department of Surgery, Louisiana State University (LSU) Health, New Orleans, LA 70112, USA; (C.H.); (O.M.)
- Department of Interdisciplinary Oncology, Louisiana Cancer Research Center, Louisiana State University (LSU) Health, New Orleans, LA 70112, USA
| | - Steven R. Post
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (K.U.F.); (M.Z.T.); (A.C.); (C.C.S.); (S.R.P.); (T.K.)
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (M.N.M.); (M.J.C.)
| | - Martin J. Cannon
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (M.N.M.); (M.J.C.)
- Department of Microbiology and Immunology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
| | - Thomas Kelly
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (K.U.F.); (M.Z.T.); (A.C.); (C.C.S.); (S.R.P.); (T.K.)
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (M.N.M.); (M.J.C.)
| | - Bolni Marius Nagalo
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (K.U.F.); (M.Z.T.); (A.C.); (C.C.S.); (S.R.P.); (T.K.)
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (M.N.M.); (M.J.C.)
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Yun WG, Han Y, Jung HS, Kwon W, Park JS, Jang JY. Emerging role of local treatment in the era of advanced systemic treatment in pancreatic cancer with liver metastasis: A systematic review and meta-analysis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2024. [PMID: 39020260 DOI: 10.1002/jhbp.12051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/19/2024]
Abstract
BACKGROUND Approximately 50% of pancreatic cancer cases are diagnosed with distant metastases, commonly in the liver, leading to poor prognosis. With modern chemotherapy regimens extending patient survival and stabilizing metastasis, there has been a rise in the use of local treatments. However, the effectiveness for local treatment remains unclear. METHODS PubMed, Embase, and Cochrane databases were searched for studies reporting the survival outcomes of pancreatic cancer cases with isolated synchronous or metachronous liver metastases who underwent curative-intent local treatment. Hazard ratios were combined using a random-effects model. RESULTS The full texts of 102 studies were screened, and 14 retrospective studies were included in the meta-analysis. Among patients with synchronous liver metastases, overall survival was significantly better in those who underwent curative-intent local treatment than in those who did not (hazard ratio [HR]: 0.35, 95% confidence interval [CI]: 0.24-0.52). Among patients with metachronous liver metastases, overall survival was also significantly better in those who underwent curative-intent local treatment than in those who did not (HR 0.37, 95% CI: 0.19-0.73). CONCLUSIONS Curative-intent local treatment may be a feasible option for highly selected pancreatic cancer cases with liver metastases. However, the optimal strategy for local treatments should be explored in future studies.
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Affiliation(s)
- Won-Gun Yun
- Department of Surgery, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Youngmin Han
- Department of Surgery, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hye-Sol Jung
- Department of Surgery, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Wooil Kwon
- Department of Surgery, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Joon Seong Park
- Department of Surgery, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jin-Young Jang
- Department of Surgery, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
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Jung JH, Won SH, Jung K, Lee JS, Lee JC, Kim JW, Yoon YS, Hwang JH, Han HS, Kim J. Analysis of Recent Improvement of Survival Outcomes in Patients with Pancreatic Cancer Who Underwent Upfront Surgery. Gut Liver 2024; 18:737-746. [PMID: 38146258 PMCID: PMC11249928 DOI: 10.5009/gnl230303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/03/2023] [Accepted: 10/16/2023] [Indexed: 12/27/2023] Open
Abstract
Background/Aims : Recently, patients with pancreatic cancer (PC) who underwent resection have exhibited improved survival outcomes, but comprehensive analysis is limited. We analyzed the trends of contributing factors. Methods : Data of patients with resected PC were retrospectively collected from the Korean Health Insurance Review and Assessment Service (HIRA) database and separately at our institution. Cox regression analysis was conducted with the data from our institution a survival prediction score was calculated using the β coefficients. Results : Comparison between the periods 2013-2015 (n=3,255) and 2016-2018 (n=3,698) revealed a difference in the median overall survival (25.9 months vs not reached, p<0.001) when analyzed with the HIRA database which was similar to our single-center data (2013-2015 [n=119] vs 2016-2018 [n=148], 20.9 months vs 32.2 months, p=0.003). Multivariable analyses revealed six factors significantly associated with better OS, and the scores were as follows: age >70 years, 1; elevated carbohydrate antigen 19-9 at diagnosis, 1; R1 resection, 1; stage N1 and N2, 1 and 3, respectively; no adjuvant treatment, 2; FOLFIRINOX or gemcitabine plus nab-paclitaxel after recurrence, 4; and other chemotherapy or supportive care only after recurrence, 5. The rate of R0 resection (69.7% vs 80.4%), use of adjuvant treatment (63.0% vs 74.3%), and utilization of FOLFIRINOX or gemcitabine plus nab-paclitaxel (25.2% vs 47.3%) as palliative chemotherapeutic regimen, all increased between the two time periods, resulting in decreased total survival prediction score (mean: 7.32 vs 6.18, p=0.004). Conclusions : Strict selection of surgical candidates, more use of adjuvant treatment, and adoption of the latest combination regimens for palliative chemotherapy after recurrence were identified as factors of recent improvement.
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Affiliation(s)
- Jae Hyup Jung
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Seung Hyun Won
- Division of Statistics, Medical Research Collaborating Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kwangrok Jung
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jun Suh Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jong-Chan Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jin Won Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jin-Hyeok Hwang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jaihwan Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Liu J, Sidiqi B, McComas K, Gogineni E, Andraos T, Crane CH, Chang DT, Goodman KA, Hall WA, Hoffe S, Mahadevan A, Narang AK, Lee P, Williams TM, Chuong MD. SBRT for Pancreatic Cancer: A Radiosurgery Society Case-Based Practical Guidelines to Challenging Cases. Pract Radiat Oncol 2024:S1879-8500(24)00147-4. [PMID: 38986901 DOI: 10.1016/j.prro.2024.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 06/17/2024] [Accepted: 06/21/2024] [Indexed: 07/12/2024]
Abstract
The use of radiation therapy (RT) for pancreatic cancer continues to be controversial, despite recent technical advances. Improvements in systemic control have created an evolving role for RT and the need for improved local tumor control, but currently, no standardized approach exists. Advances in stereotactic body RT, motion management, real-time image guidance, and adaptive therapy have renewed hopes of improved outcomes in this devastating disease with one of the lowest survival rates. This case-based guide provides a practical framework for delivering stereotactic body RT for locally advanced pancreatic cancer. In conjunction with multidisciplinary care, an intradisciplinary approach should guide treatment of the high-risk cases outlined within these guidelines for prospective peer review and treatment safety discussions.
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Affiliation(s)
- Jason Liu
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, California.
| | - Baho Sidiqi
- Department of Radiation Oncology, Northwell Health Cancer Institute, New Hyde Park, New York
| | - Kyra McComas
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennesse
| | - Emile Gogineni
- Department of Radiation Oncology, Ohio State James Cancer Center, Columbus, Ohio
| | - Therese Andraos
- Department of Radiation Oncology, Ohio State James Cancer Center, Columbus, Ohio
| | - Christopher H Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Daniel T Chang
- Department of Radiation Oncology, University of Michigan Health, Ann Arbor, Michigan
| | - Karyn A Goodman
- Department of Radiation Oncology, Mount Sinai Health, New York City, New York
| | - William A Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sarah Hoffe
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Anand Mahadevan
- Department of Radiation Oncology, NYU Langone Health, New York City, New York
| | - Amol K Narang
- Department of Radiation Oncology, Johns Hopkins University Kimmel Cancer Center, Baltimore, Maryland
| | - Percy Lee
- Department of Radiation Oncology, City of Hope Lennar Cancer Center, Irvine, California
| | - Terence M Williams
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, California
| | - Michael D Chuong
- Department of Radiation Oncology, Baptist Health South Florida, Miami, Florida
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Chaudhari VA, Kunte AR, Chopde AN, Ostwal V, Ramaswamy A, Engineer R, Bhargava P, Bal M, Shetty N, Kulkarni S, Patkar S, Bhandare MS, Shrikhande SV. Evolution and improved outcomes in the era of multimodality treatment for extended pancreatectomy. BJS Open 2024; 8:zrae065. [PMID: 39088732 PMCID: PMC11293468 DOI: 10.1093/bjsopen/zrae065] [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: 12/01/2023] [Revised: 04/07/2024] [Accepted: 05/02/2024] [Indexed: 08/03/2024] Open
Abstract
BACKGROUND The evolution and outcomes of extended pancreatectomies at a single institute over 15 years are presented in this study. METHODS A retrospective analysis of the institutional database was performed from 2015 to 2022 (period B). Patients undergoing extended pancreatic resections, as defined by the International Study Group for Pancreatic Surgery, were included. Perioperative and survival outcomes were compared with data from 2007-2015 (period A). Regression analyses were used to identify factors affecting postoperative and long-term survival outcomes. RESULTS A total of 197 (16.1%) patients underwent an extended resection in period B compared to 63 (9.2%) in period A. Higher proportions of borderline resectable (5 (18.5%) versus 51 (47.7%), P = 0.011) and locally advanced tumours (1 (3.7%) versus 24 (22.4%), P < 0.001) were resected in period B with more frequent use of neoadjuvant therapy (6 (22.2%) versus 79 (73.8%), P < 0.001). Perioperative mortality (4 (6.0%) versus 12 (6.1%), P = 0.81) and morbidity (23 (36.5%) versus 83 (42.1%), P = 0.57) rates were comparable. The overall survival for patients with pancreatic adenocarcinoma was similar in both periods (17.5 (95% c.i. 6.77 to 28.22) versus 18.3 (95% c.i. 7.91 to 28.68) months, P = 0.958). Resectable, node-positive tumours had a longer disease-free survival (DFS) in period B (5.81 (95% c.i. 1.73 to 9.89) versus 14.03 (95% c.i. 5.7 to 22.35) months, P = 0.018). CONCLUSION Increasingly complex pancreatic resections were performed with consistent perioperative outcomes and improved DFS compared to the earlier period. A graduated approach to escalating surgical complexity, multimodality treatment, and judicious patient selection enables the resection of advanced pancreatic tumours.
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Affiliation(s)
- Vikram A Chaudhari
- GI & HPB Surgical Services, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Aditya R Kunte
- GI & HPB Surgical Services, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Amit N Chopde
- GI & HPB Surgical Services, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Vikas Ostwal
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Anant Ramaswamy
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Reena Engineer
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Prabhat Bhargava
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Munita Bal
- Department of Pathology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Nitin Shetty
- Department of Interventional Radiology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Suyash Kulkarni
- Department of Interventional Radiology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Shraddha Patkar
- GI & HPB Surgical Services, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Manish S Bhandare
- GI & HPB Surgical Services, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Shailesh V Shrikhande
- GI & HPB Surgical Services, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
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22
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Dillon DL, Park JY, Mederos MA, Seo YJ, King J, Hines J, Donahue T, Girgis MD. Neoadjuvant chemotherapy is associated with improved disease-free survival in pancreatic cancer patients undergoing pancreaticoduodenectomy with vascular resection. J Surg Oncol 2024; 130:72-82. [PMID: 38726668 DOI: 10.1002/jso.27674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 04/21/2024] [Indexed: 07/15/2024]
Abstract
BACKGROUND AND OBJECTIVES Neoadjuvant chemotherapy (NAC) is becoming favored for all pancreatic adenocarcinoma (PDAC). Patients with seemingly resectable disease infrequently still display vascular involvement intraoperatively. Outcomes following NAC versus upfront surgery in patients undergoing pancreaticoduodenectomy (PD) with vascular resection are unknown. METHODS We performed a retrospective cohort study of PDAC patients who underwent PD with vascular resection between January 1, 2013, to December 31, 2020, within a single academic center. Clinicopathologic characteristics and disease-free survival (DFS) were compared between NAC versus upfront surgery cohorts using the Kaplan-Meier estimate and Cox proportional-hazards regression model. RESULTS Eighty-one patients who underwent PD with vascular resection for PDAC were included. Forty-six patients (56%) received NAC. The NAC cohort more often had pathologic N0 status (47.8% vs. 8.6%, p < 0.001), had decreased vascular invasion (11% vs. 40%, p = 0.002), and completed chemotherapy (80% vs. 40%, p < 0.01). The NAC cohort demonstrated improved DFS (40.5 vs. 14.3 months, p = 0.007). In multivariable analysis, NAC remained independently associated with increased DFS (HR = 0.48, p = 0.02). CONCLUSIONS NAC was associated with improved clinicopathologic outcomes and DFS in PD with vascular resection. These findings demonstrate the advantage of NAC in PDAC patients undergoing PD with vascular resection.
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Affiliation(s)
- Dustin L Dillon
- Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Joon Y Park
- Department of Surgery, Division of Surgical Oncology, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Michael A Mederos
- Department of Surgery, Division of Surgical Oncology, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Young-Ji Seo
- Department of Surgery, Division of Surgical Oncology, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Jonathan King
- Department of Surgery, Division of Surgical Oncology, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Joe Hines
- Department of Surgery, Division of Surgical Oncology, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Timothy Donahue
- Department of Surgery, Division of Surgical Oncology, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Mark D Girgis
- Department of Surgery, Division of Surgical Oncology, UCLA David Geffen School of Medicine, Los Angeles, California, USA
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Bugazia D, Al-Najjar E, Esmail A, Abdelrahim S, Abboud K, Abdelrahim A, Umoru G, Rayyan HA, Abudayyeh A, Al Moustafa AE, Abdelrahim M. Pancreatic ductal adenocarcinoma: the latest on diagnosis, molecular profiling, and systemic treatments. Front Oncol 2024; 14:1386699. [PMID: 39011469 PMCID: PMC11247645 DOI: 10.3389/fonc.2024.1386699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 05/30/2024] [Indexed: 07/17/2024] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is currently the fourth leading cause of death in the United States and is expected to be ranked second in the next 10 years due to poor prognosis and a rising incidence. Distant metastatic PDAC is associated with the worst prognosis among the different phases of PDAC. The diagnostic options for PDAC are convenient and available for staging, tumor response evaluation, and management of resectable or borderline resectable PDAC. However, imaging is crucial in PDAC diagnosis, monitoring, resectability appraisal, and response evaluation. The advancement of medical technologies is evolving, hence the use of imaging in PDAC treatment options has grown as well as the utilization of ctDNA as a tumor marker. Treatment options for metastatic PDAC are minimal with the primary goal of therapy limited to symptom relief or palliation, especially in patients with low functional capacity at the point of diagnosis. Molecular profiling has shown promising potential solutions that would push the treatment boundaries for patients with PDAC. In this review, we will discuss the latest updates from evidence-based guidelines regarding diagnosis, therapy response evaluation, prognosis, and surveillance, as well as illustrating novel therapies that have been recently investigated for PDAC, in addition to discussing the molecular profiling advances in PDAC.
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Affiliation(s)
- Doaa Bugazia
- Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Ebtesam Al-Najjar
- Section of GI Oncology, Department of Medical Oncology, Houston Methodist Cancer Center, Houston, TX, United States
| | - Abdullah Esmail
- Section of GI Oncology, Department of Medical Oncology, Houston Methodist Cancer Center, Houston, TX, United States
| | - Saifudeen Abdelrahim
- Challenge Early College HS, Houston Community College, Houston, TX, United States
| | - Karen Abboud
- Department of Pharmacy, Houston Methodist Hospital, Houston, TX, United States
| | | | - Godsfavour Umoru
- Department of Pharmacy, Houston Methodist Hospital, Houston, TX, United States
| | - Hashem A Rayyan
- Department of Medicine, Faculty of Medicine, The University of Jordan, Amman, Jordan
| | - Ala Abudayyeh
- Section of Nephrology, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | | | - Maen Abdelrahim
- Section of GI Oncology, Department of Medical Oncology, Houston Methodist Cancer Center, Houston, TX, United States
- Department of Medicine, Weill Cornell Medical College, New York, NY, United States
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24
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Kirkegård J, Gaber C, Heide-Jørgensen U, Fristrup CW, Lund JL, Cronin-Fenton D, Mortensen FV. Effect of surgery versus chemotherapy in pancreatic cancer patients: a target trial emulation. J Natl Cancer Inst 2024; 116:1072-1079. [PMID: 38310365 DOI: 10.1093/jnci/djae024] [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: 09/13/2023] [Revised: 12/08/2023] [Accepted: 01/28/2024] [Indexed: 02/05/2024] Open
Abstract
BACKGROUND To estimate the causal effect of surgery vs chemotherapy on survival in patients with T1-3NxM0 pancreatic cancer in a rigorous framework addressing selection bias and immortal time bias. METHODS We used population-based Danish health-care registries to conduct a cohort study emulating a hypothetical randomized trial to estimate the absolute difference in survival, comparing surgery with chemotherapy. We included pancreatic cancer patients diagnosed during 2008-2021. Exposure was surgery or chemotherapy initiated within a 16-week grace period after diagnosis. At the time of diagnosis, data of each patient were duplicated; one copy was assigned to the surgery protocol, and one copy to the chemotherapy protocol of the hypothetical trial. Copies were censored when the assigned treatment deviated from the observed treatment. To account for informative censoring, uncensored patients were weighted according to confounders. For comparison, we also applied a more conventional analysis using propensity score-based inverse probability weighting. RESULTS We included 1744 patients with a median age of 68 years: 73.6% underwent surgery, and 18.6% had chemotherapy without surgery; 7.8% received no treatment. The 3-year survival was 39.7% (95% confidence interval [CI] = 36.7% to 42.6%) after surgery and 22.7% (95% CI = 17.7% to 28.4%) after chemotherapy, corresponding to an absolute difference of 17.0% (95% CI = 10.8% to 23.1%). In the conventional survival analysis, this difference was 23.0% (95% CI = 17.0% to 29.0%). CONCLUSION Surgery was superior to chemotherapy in achieving long-term survival for pancreatic cancer. The difference comparing surgery and chemotherapy was substantially smaller when using the clone-censor-weight approach than conventional survival analysis.
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Affiliation(s)
- Jakob Kirkegård
- Department of Surgery, HPB Section, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Charles Gaber
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois, Chicago, IL, USA
| | - Uffe Heide-Jørgensen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Jennifer L Lund
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Deirdre Cronin-Fenton
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Frank Viborg Mortensen
- Department of Surgery, HPB Section, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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25
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Tesson M, Morton JP. The preclinical gap in pancreatic cancer and radiotherapy. Dis Model Mech 2024; 17:dmm050703. [PMID: 38979684 PMCID: PMC11261628 DOI: 10.1242/dmm.050703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2024] Open
Abstract
Pancreatic ductal adenocarcinoma is an aggressive malignancy with limited treatment options. Chemotherapy offers little benefit and, although there is some evidence that radiotherapy may improve response, its use in the clinical management of pancreatic cancer remains controversial due to conflicting reports on its survival benefit. There has also been a lack of clinical trials that directly investigate the efficacy of radiotherapy in pancreatic cancer. The limited progress in the development of radiotherapeutic strategies in pancreatic cancer can be attributed, at least in part, to a dearth of preclinical research and our limited understanding of the effects of radiation on the pancreatic tumour microenvironment. In this Perspective, we discuss how insight into the immunosuppressive tumour microenvironment and the complex signalling between tumour and stromal cells following radiation is needed to develop effective radiosensitising strategies for pancreatic cancer. We also highlight that to have the best chance for successful clinical translation, more preclinical research is required in appropriately complex models.
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Affiliation(s)
- Mathias Tesson
- Cancer Research UK Scotland Institute, Switchback Rd, Glasgow G61 1BD, UK
| | - Jennifer P. Morton
- Cancer Research UK Scotland Institute, Switchback Rd, Glasgow G61 1BD, UK
- School of Cancer Sciences, University of Glasgow, Glasgow G61 1QH, UK
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26
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Yamada D, Kobayashi S, Takahashi H, Iwagami Y, Akita H, Asukai K, Shimizu J, Yamada T, Tanemura M, Yokoyama S, Tsujie M, Asaoka T, Takeda Y, Morimoto O, Tomokuni A, Doki Y, Eguchi H. ASO Author Reflections: Which was the Better Regimen (Gemcitabine Plus Nab-Paclitaxel Versus Gemcitabine Plus S-1) as Neoadjuvant Chemotherapy for Localized Pancreatic Ductal Adenocarcinoma (R/BR-PDAC)? Ann Surg Oncol 2024; 31:4702-4703. [PMID: 38722422 DOI: 10.1245/s10434-024-15244-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 03/14/2024] [Indexed: 06/14/2024]
Affiliation(s)
- Daisaku Yamada
- Gastroenterological Surgery, Osaka University, Graduate School of Medicine, Suita, Japan
| | - Shogo Kobayashi
- Gastroenterological Surgery, Osaka University, Graduate School of Medicine, Suita, Japan.
| | - Hidenori Takahashi
- Gastroenterological Surgery, Osaka University, Graduate School of Medicine, Suita, Japan
| | - Yoshifumi Iwagami
- Gastroenterological Surgery, Osaka University, Graduate School of Medicine, Suita, Japan
| | - Hirofumi Akita
- Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Kei Asukai
- Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Junzo Shimizu
- Gastroenterological Surgery, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Terumasa Yamada
- Gastroenterological Surgery, Higashiosaka City Medical Center, Higashiosaka, Japan
| | - Masahiro Tanemura
- Gastroenterological Surgery, Rinku General Medical Center, Izumisano, Japan
| | - Shigekazu Yokoyama
- Gastroenterological Surgery, Hyogo Prefectural Nishinomiya Hospital, Nishinomiya, Japan
| | - Masanori Tsujie
- Gastroenterological Surgery, Osaka Rosai Hospital, Sakai, Japan
| | - Tadafumi Asaoka
- Gastroenterological Surgery, Osaka Police Hospital, Osaka, Japan
| | - Yutaka Takeda
- Gastroenterological Surgery, Kansai Rosai Hospital, Amagasaki, Japan
| | - Osakuni Morimoto
- Surgery, Japan Community Health Care Organization Osaka Hospital, Osaka, Japan
| | - Akira Tomokuni
- Gastroenterological Surgery, Osaka General Medical Center, Osaka, Japan
| | - Yuichiro Doki
- Gastroenterological Surgery, Osaka University, Graduate School of Medicine, Suita, Japan
| | - Hidetoshi Eguchi
- Gastroenterological Surgery, Osaka University, Graduate School of Medicine, Suita, Japan
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27
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Yamada D, Kobayashi S, Takahashi H, Iwagami Y, Akita H, Asukai K, Shimizu J, Yamada T, Tanemura M, Yokoyama S, Tsujie M, Asaoka T, Takeda Y, Morimoto O, Tomokuni A, Doki Y, Eguchi H. Results of a Randomized Clinical Study of Gemcitabine Plus Nab-Paclitaxel Versus Gemcitabine Plus S-1 as Neoadjuvant Chemotherapy for Resectable and Borderline Resectable Pancreatic Ductal Adenocarcinoma (RCT, CSGO-HBP-015). Ann Surg Oncol 2024; 31:4621-4633. [PMID: 38546797 PMCID: PMC11164807 DOI: 10.1245/s10434-024-15199-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 03/05/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND The optimal neoadjuvant chemotherapy (NAC) regimen for patients with localized pancreatic ductal adenocarcinoma (PDAC) remains uncertain. This trial aimed to evaluate the efficacy and safety of two neoadjuvant chemotherapy (NAC) regimens, gemcitabine plus nab-paclitaxel (GA) and gemcitabine plus S-1 (GS), in patients with resectable/borderline-resectable (R/BR) PDAC. PATIENTS AND METHODS Treatment-naïve patients with R/BR-PDAC were enrolled and randomly allocated. They received two cycles (2 months) of each standard protocol, followed by radical surgery for those without tumor progression in general hospitals belonging to our intergroup. The primary endpoint was to determine the superior regimen on the basis of achieving a 10% increase in the rate of patients with progression-free survival (PFS) at 2 years from allocation. RESULTS A total of 100 patients were enrolled, with 94 patients randomly assigned to the GS arm (N = 46) or GA arm (N = 48). The 2-year PFS rates did not show the stipulated difference [GA, 31% (24-38%)/GS, 26% (18-33%)], but the Kaplan-Myer analysis showed significance (median PFS, GA/GS 14 months/9 months, P = 0.048; HR 0.71). Secondary endpoint comparisons yielded the following results (GA/GS arm, P-value): rates of severe adverse events during NAC, 73%/78%, P = 0.55; completion rates of the stipulated NAC, 92%/83%, P = 0.71; resection rates, 85%/72%, P = 0.10; average tumor marker (CA19-9) reduction rates, -50%/-21%, P = 0.01; average numbers of lymph node metastasis, 1.7/3.2, P = 0.04; and median overall survival times, 42/22 months, P = 0.26. CONCLUSIONS This study found that GA and GS are viable neoadjuvant treatment regimens in R/BR-PDAC. Although the GA group exhibited a favorable PFS outcome, the primary endpoint was not achieved.
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Affiliation(s)
- Daisaku Yamada
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Shogo Kobayashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan.
| | - Hidenori Takahashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Yoshifumi Iwagami
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Hirofumi Akita
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Kei Asukai
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Junzo Shimizu
- Department of Gastroenterological Surgery, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Terumasa Yamada
- Department of Gastroenterological Surgery, Higashiosaka City Medical Center, Higashiosaka, Japan
| | - Masahiro Tanemura
- Department of Gastroenterological Surgery, Rinku General Medical Center, Izumisano, Japan
| | - Shigekazu Yokoyama
- Department of Gastroenterological Surgery, Hyogo Prefectural Nishinomiya Hospital, Nishinomiya, Japan
| | - Masanori Tsujie
- Department of Gastroenterological Surgery, Osaka Rosai Hospital, Sakai, Japan
| | - Tadafumi Asaoka
- Department of Gastroenterological Surgery, Osaka Police Hospital, Osaka, Japan
| | - Yutaka Takeda
- Department of Gastroenterological Surgery, Kansai Rosai Hospital, Amagasaki, Japan
| | - Osakuni Morimoto
- Department of Surgery, Japan Community Health Care Organization Osaka Hospital, Osaka, Japan
| | - Akira Tomokuni
- Department of Gastroenterological Surgery, Osaka General Medical Center, Osaka, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
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28
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Saúde-Conde R, El Ghali B, Navez J, Bouchart C, Van Laethem JL. Total Neoadjuvant Therapy in Localized Pancreatic Cancer: Is More Better? Cancers (Basel) 2024; 16:2423. [PMID: 39001485 PMCID: PMC11240662 DOI: 10.3390/cancers16132423] [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: 05/15/2024] [Revised: 06/24/2024] [Accepted: 06/24/2024] [Indexed: 07/16/2024] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) poses a significant challenge in oncology due to its advanced stage upon diagnosis and limited treatment options. Surgical resection, the primary curative approach, often results in poor long-term survival rates, leading to the exploration of alternative strategies like neoadjuvant therapy (NAT) and total neoadjuvant therapy (TNT). While NAT aims to enhance resectability and overall survival, there appears to be potential for improvement, prompting consideration of alternative neoadjuvant strategies integrating full-dose chemotherapy (CT) and radiotherapy (RT) in TNT approaches. TNT integrates chemotherapy and radiotherapy prior to surgery, potentially improving margin-negative resection rates and enabling curative resection for locally advanced cases. The lingering question: is more always better? This article categorizes TNT strategies into six main groups based on radiotherapy (RT) techniques: (1) conventional chemoradiotherapy (CRT), (2) the Dutch PREOPANC approach, (3) hypofractionated ablative intensity-modulated radiotherapy (HFA-IMRT), and stereotactic body radiotherapy (SBRT) techniques, which further divide into (4) non-ablative SBRT, (5) nearly ablative SBRT, and (6) adaptive ablative SBRT. A comprehensive analysis of the literature on TNT is provided for both borderline resectable pancreatic cancer (BRPC) and locally advanced pancreatic cancer (LAPC), with detailed sections for each.
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Affiliation(s)
- Rita Saúde-Conde
- Digestive Oncology Department, Hôpitaux Universitaires de Bruxelles (HUB), Université Libre de Bruxelles, 1070 Brussels, Belgium;
| | - Benjelloun El Ghali
- Department of Radiation Oncology, Hôpitaux Universitaires de Bruxelles (HUB), Institut Jules Bordet, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium; (B.E.G.); (C.B.)
| | - Julie Navez
- Department of Abdominal Surgery and Transplantation, Hôpitaux Universitaires de Bruxelles (HUB), Hopital Erasme, Université Libre de Bruxelles, 1070 Brussels, Belgium;
| | - Christelle Bouchart
- Department of Radiation Oncology, Hôpitaux Universitaires de Bruxelles (HUB), Institut Jules Bordet, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium; (B.E.G.); (C.B.)
| | - Jean-Luc Van Laethem
- Digestive Oncology Department, Hôpitaux Universitaires de Bruxelles (HUB), Université Libre de Bruxelles, 1070 Brussels, Belgium;
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29
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Dallavalle S, Campagnoli G, Pastena P, Martinino A, Schiliró D, Giovinazzo F. New Frontiers in Pancreatic Cancer Management: Current Treatment Options and the Emerging Role of Neoadjuvant Therapy. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1070. [PMID: 39064499 PMCID: PMC11278520 DOI: 10.3390/medicina60071070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 06/24/2024] [Accepted: 06/24/2024] [Indexed: 07/28/2024]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) ranks among the 15 most prevalent cancers globally, characterized by aggressive growth and late-stage diagnosis. Advances in imaging and surgical techniques have redefined the classification of pancreatic PDAC into resectable, borderline resectable, and locally advanced pancreatic cancer. While surgery remains the most effective treatment, only 20% of patients are eligible at diagnosis, necessitating innovative strategies to improve outcomes. Therefore, traditional treatment paradigms, primarily surgical resection for eligible patients, are increasingly supplemented by neoadjuvant therapies (NAT), which include chemotherapy, radiotherapy, or a combination of both. By administering systemic therapy prior to surgery, NAT aims to reduce tumor size and increase the feasibility of complete surgical resection, thus enhancing overall survival rates and potentially allowing more patients to undergo curative surgeries. Recent advances in treatment protocols, such as FOLFIRINOX and gemcitabine-nab-paclitaxel, now integral to NAT strategies, have shown promising results in increasing the proportion of patients eligible for surgery by effectively reducing tumor size and addressing micrometastatic disease. Additionally, they offer improved response rates and survival benefits compared to traditional regimes. Despite these advancements, the role of NAT continues to evolve, necessitating ongoing research to optimize treatment regimens, minimize adverse effects, and identify patient populations that would benefit most from these approaches. Through a detailed analysis of current literature and recent clinical trials, this review highlights the transformative potential of NAT in managing PDAC, especially in patients with borderline resectable or locally advanced stages, promising a shift towards more personalized and effective management strategies for PDAC.
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Affiliation(s)
- Sofia Dallavalle
- Faculty of Medicine and Surgery, University of Milan, 20122 Milan, Italy; (S.D.); (G.C.)
| | - Gabriele Campagnoli
- Faculty of Medicine and Surgery, University of Milan, 20122 Milan, Italy; (S.D.); (G.C.)
| | - Paola Pastena
- Department of Medicine, Stony Brook Medicine, Stony Brook, NY 11794, USA;
| | | | - Davide Schiliró
- Department of Surgery, Duke University, Durham, NC 27710, USA
| | - Francesco Giovinazzo
- Department of Surgery, Saint Camillus Hospital, 31100 Treviso, Italy
- Department of Surgery, UniCamillus-Saint Camillus International University of Health Sciences, 00131 Rome, Italy
- Department of Surgery, Agostino Gemelli University Hospital, 00168 Rome, Italy
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30
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Konishi T, Takano S, Takayashiki T, Suzuki D, Sakai N, Hosokawa I, Mishima T, Nishino H, Suzuki K, Nakada S, Ohtsuka M. Preoperative Prediction of Long-Term Survival After Surgery in Patients with Resectable Pancreatic Ductal Adenocarcinoma. Ann Surg Oncol 2024:10.1245/s10434-024-15648-4. [PMID: 38926210 DOI: 10.1245/s10434-024-15648-4] [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: 02/29/2024] [Accepted: 06/10/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Although some clinical trials have demonstrated the benefits of neoadjuvant therapy for resectable pancreatic ductal adenocarcinoma (PDAC), its optimal candidate has not been clarified. This study aimed to detect predictive prognostic factors for resectable PDAC patients who underwent upfront surgery and identify patient cohorts with long-term survival without neoadjuvant therapy. PATIENTS AND METHODS A total of 232 patients with resectable PDAC who underwent upfront surgery between January 2008 and December 2019 were evaluated. RESULTS The median overall survival (OS) time and 5-year OS rate of resectable PDAC with upfront surgery was 31.5 months and 33.3%, respectively. Multivariate analyses identified tumor diameter in computed tomography (CT) ≤ 19 mm [hazard ratio (HR) 0.40, p < 0.001], span-1 within the normal range (HR 0.54, p = 0.023), prognostic nutritional index (PNI) ≥ 44.31 (HR 0.51, p < 0.001), and lymphocyte-to-monocyte ratio (LMR) ≥ 3.79 (HR 0.51, p < 0.001) as prognostic factors that influence favorable prognoses after upfront surgery. According to the prognostic prediction model based on these four factors, patients with four favorable prognostic factors had a better prognosis with a 5-year OS rate of 82.4% compared to others (p < 0.001). These patients had a high R0 resection rate and a low frequency of tumor recurrence after upfront surgery. CONCLUSIONS We identified patients with long-term survival after upfront surgery by prognostic prediction model consisting of tumor diameter in CT, span-1, PNI, and LMR. Evaluation of anatomical, biological, nutritional, and inflammatory factors may be valuable to introduce an optimal treatment strategy for resectable PDAC.
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Affiliation(s)
- Takanori Konishi
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Shigetsugu Takano
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Tsukasa Takayashiki
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Daisuke Suzuki
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Nozomu Sakai
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Isamu Hosokawa
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Takashi Mishima
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Hitoe Nishino
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Kensuke Suzuki
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Shinichiro Nakada
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Masayuki Ohtsuka
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan.
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31
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Quero G, De Sio D, Fiorillo C, Lucinato C, Panza E, Biffoni B, Langellotti L, Laterza V, Scaglione G, Taglioni F, Massimiani G, Menghi R, Rosa F, Mezza T, Alfieri S, Tondolo V. Resection Margin Status and Long-Term Outcomes after Pancreaticoduodenectomy for Ductal Adenocarcinoma: A Tertiary Referral Center Analysis. Cancers (Basel) 2024; 16:2347. [PMID: 39001409 PMCID: PMC11240367 DOI: 10.3390/cancers16132347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 06/14/2024] [Accepted: 06/24/2024] [Indexed: 07/16/2024] Open
Abstract
The influencing role of resection margin (R) status on long-term outcomes, namely overall (OS) and disease-free survival (DFS), after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) is not still clear. The aim of this study is to evaluate the prognostic impact of R status after PD and to define tumor characteristics associated with a positive resection margin (R1). All PDs for PDAC performed between 2012 and 2023 were retrospectively enrolled. The effect of R status, patient clinico-demographic features, and tumor features on OS and DFS were assessed. One-hundred and sixty-seven patients who underwent PD for PDAC were included in the study. R0 was achieved in 105 cases (62.8%), while R1 was evidenced in 62 patients (37.1%). R1 was associated with a decreased OS (23 (13-38) months) as compared to R0 (36 (21-53) months) (p = 0.003). Similarly, DFS was shorter in R1 patients (10 (6-25) months) as compared to the R0 cohort (18 (9-70) months) (p = 0.004), with a consequent higher recurrence rate in cases of R1 (74.2% vs. 64.8% in the R0 group; p = 0.04). In the multivariate analysis, R1 and positive lymph nodes (N+) were the only independent influencing factors for OS (OR: 1.6; 95% CI: 1-2.5; p = 0.03 and OR: 1.7; 95% CI: 1-2.8; p = 0.04) and DFS (OR: 1.5; 95% CI: 1-2.1; p = 0.04 and OR: 1.8; 95% CI: 1.1-2.7; p = 0.009). Among 111 patients with N+ disease, R1 was associated with a significantly decreased DFS (10 (8-11) months) as compared to R0N+ patients (16 (11-21) months) (p = 0.05). In conclusion, the achievement of a negative resection margin is associated with survival benefits, particularly in cases of N1 disease. In addition, R0 was recognized as an independent prognostic feature for both OS and DFS. This further outlines the relevant role of radical surgery on long-term outcomes.
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Affiliation(s)
- Giuseppe Quero
- Pancreatic Surgery Unit, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (G.Q.); (C.F.); (C.L.); (E.P.); (B.B.); (L.L.); (V.L.); (F.T.); (G.M.); (R.M.); (F.R.); (S.A.)
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy;
- Dipartimento di Scienze Mediche e Chirurgiche, Università Cattolica del Sacro Cuore di Roma, 00168 Rome, Italy;
| | - Davide De Sio
- Pancreatic Surgery Unit, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (G.Q.); (C.F.); (C.L.); (E.P.); (B.B.); (L.L.); (V.L.); (F.T.); (G.M.); (R.M.); (F.R.); (S.A.)
| | - Claudio Fiorillo
- Pancreatic Surgery Unit, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (G.Q.); (C.F.); (C.L.); (E.P.); (B.B.); (L.L.); (V.L.); (F.T.); (G.M.); (R.M.); (F.R.); (S.A.)
| | - Chiara Lucinato
- Pancreatic Surgery Unit, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (G.Q.); (C.F.); (C.L.); (E.P.); (B.B.); (L.L.); (V.L.); (F.T.); (G.M.); (R.M.); (F.R.); (S.A.)
| | - Edoardo Panza
- Pancreatic Surgery Unit, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (G.Q.); (C.F.); (C.L.); (E.P.); (B.B.); (L.L.); (V.L.); (F.T.); (G.M.); (R.M.); (F.R.); (S.A.)
| | - Beatrice Biffoni
- Pancreatic Surgery Unit, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (G.Q.); (C.F.); (C.L.); (E.P.); (B.B.); (L.L.); (V.L.); (F.T.); (G.M.); (R.M.); (F.R.); (S.A.)
| | - Lodovica Langellotti
- Pancreatic Surgery Unit, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (G.Q.); (C.F.); (C.L.); (E.P.); (B.B.); (L.L.); (V.L.); (F.T.); (G.M.); (R.M.); (F.R.); (S.A.)
| | - Vito Laterza
- Pancreatic Surgery Unit, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (G.Q.); (C.F.); (C.L.); (E.P.); (B.B.); (L.L.); (V.L.); (F.T.); (G.M.); (R.M.); (F.R.); (S.A.)
| | - Giulia Scaglione
- Unità Operativa Complessa Anatomia Patologica Generale, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy;
| | - Flavia Taglioni
- Pancreatic Surgery Unit, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (G.Q.); (C.F.); (C.L.); (E.P.); (B.B.); (L.L.); (V.L.); (F.T.); (G.M.); (R.M.); (F.R.); (S.A.)
| | - Giuseppe Massimiani
- Pancreatic Surgery Unit, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (G.Q.); (C.F.); (C.L.); (E.P.); (B.B.); (L.L.); (V.L.); (F.T.); (G.M.); (R.M.); (F.R.); (S.A.)
| | - Roberta Menghi
- Pancreatic Surgery Unit, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (G.Q.); (C.F.); (C.L.); (E.P.); (B.B.); (L.L.); (V.L.); (F.T.); (G.M.); (R.M.); (F.R.); (S.A.)
| | - Fausto Rosa
- Pancreatic Surgery Unit, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (G.Q.); (C.F.); (C.L.); (E.P.); (B.B.); (L.L.); (V.L.); (F.T.); (G.M.); (R.M.); (F.R.); (S.A.)
- Dipartimento di Scienze Mediche e Chirurgiche, Università Cattolica del Sacro Cuore di Roma, 00168 Rome, Italy;
| | - Teresa Mezza
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy;
- Dipartimento di Scienze Mediche e Chirurgiche, Università Cattolica del Sacro Cuore di Roma, 00168 Rome, Italy;
| | - Sergio Alfieri
- Pancreatic Surgery Unit, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (G.Q.); (C.F.); (C.L.); (E.P.); (B.B.); (L.L.); (V.L.); (F.T.); (G.M.); (R.M.); (F.R.); (S.A.)
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy;
- Dipartimento di Scienze Mediche e Chirurgiche, Università Cattolica del Sacro Cuore di Roma, 00168 Rome, Italy;
| | - Vincenzo Tondolo
- Dipartimento di Scienze Mediche e Chirurgiche, Università Cattolica del Sacro Cuore di Roma, 00168 Rome, Italy;
- General Surgery Unit, Fatebenefratelli Isola Tiberina—Gemelli Isola, 00186 Rome, Italy
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Litjens G, Nakamoto A, Brosens LAA, Maas MC, Scheenen TWJ, Zámecnik P, van Geenen EJM, Prokop M, van Laarhoven KJHM, Hermans JJ. Ferumoxtran-10-enhanced MRI for pre-operative metastatic lymph node detection in pancreatic, duodenal, or periampullary adenocarcinoma. Eur Radiol 2024:10.1007/s00330-024-10838-w. [PMID: 38907886 DOI: 10.1007/s00330-024-10838-w] [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: 01/10/2024] [Revised: 04/18/2024] [Accepted: 04/26/2024] [Indexed: 06/24/2024]
Abstract
OBJECTIVES To assess 3-Tesla (3-T) ultra-small superparamagnetic iron oxide (USPIO)-enhanced MRI in detecting lymph node (LN) metastases for resectable adenocarcinomas of the pancreas, duodenum, or periampullary region in a node-to-node validation against histopathology. METHODS Twenty-seven consecutive patients with a resectable pancreatic, duodenal, or periampullary adenocarcinoma were enrolled in this prospective single expert centre study. Ferumoxtran-10-enhanced 3-T MRI was performed pre-surgery. LNs found on MRI were scored for suspicion of metastasis by two expert radiologists using a dedicated scoring system. Node-to-node matching from in vivo MRI to histopathology was performed using a post-operative ex vivo 7-T MRI of the resection specimen. Sensitivity and specificity were calculated using crosstabs. RESULTS Eighteen out of 27 patients (median age 65 years, 11 men) were included in the final analysis (pre-surgery withdrawal n = 4, not resected because of unexpected metastases peroperatively n = 2, and excluded because of inadequate contrast-agent uptake n = 3). On MRI 453 LNs with a median size of 4.0 mm were detected, of which 58 (13%) were classified as suspicious. At histopathology 385 LNs with a median size of 5.0 mm were found, of which 45 (12%) were metastatic. For 55 LNs node-to-node matching was possible. Analysis of these 55 matched LNs, resulted in a sensitivity and specificity of 83% (95% CI: 36-100%) and 92% (95% CI: 80-98%), respectively. CONCLUSION USPIO-enhanced MRI is a promising technique to preoperatively detect and localise LN metastases in patients with pancreatic, duodenal, or periampullary adenocarcinoma. CLINICAL RELEVANCE STATEMENT Detection of (distant) LN metastases with USPIO-enhanced MRI could be used to determine a personalised treatment strategy that could involve neoadjuvant or palliative chemotherapy, guided resection of distant LNs, or targeted radiotherapy. REGISTRATION The study was registered on clinicaltrials.gov NCT04311047. https://clinicaltrials.gov/ct2/show/NCT04311047?term=lymph+node&cond=Pancreatic+Cancer&cntry=NL&draw=2&rank=1 . KEY POINTS LN metastases of pancreatic, duodenal, or periampullary adenocarcinoma cannot be reliably detected with current imaging. This technique detected LN metastases with a sensitivity and specificity of 83% and 92%, respectively. MRI with ferumoxtran-10 is a promising technique to improve preoperative staging in these cancers.
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Affiliation(s)
- Geke Litjens
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Atsushi Nakamoto
- Department of Radiology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Lodewijk A A Brosens
- Department of Pathology, Radboud University Medical Center, Nijmegen, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marnix C Maas
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Tom W J Scheenen
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Patrik Zámecnik
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mathias Prokop
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kees J H M van Laarhoven
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - John J Hermans
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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Yu KH. Advances in Systemic Therapy in Pancreatic Cancer. Hematol Oncol Clin North Am 2024; 38:617-627. [PMID: 38575456 DOI: 10.1016/j.hoc.2024.03.002] [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: 04/06/2024]
Abstract
Substantial progress has been made toward understanding biology and developing new therapies for pancreatic ductal adenocarcinoma (PDAC). In this review, new insights from genomic profiling, as well as implications for treatment and prognosis, are discussed. New standards of care approaches with a focus on drug therapies are discussed for the treatment of resectable and advanced PDAC. The role of targeted and immune therapies remains limited; cohorts likely to benefit from these approaches are discussed. Promising, preliminary results regarding experimental therapies are reviewed.
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Affiliation(s)
- Kenneth H Yu
- Gastrointestinal Oncology Service, Cell Therapy Service, Memorial Sloan Kettering Cancer Center, 300 E 66th Street, New York, NY 10065, USA.
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34
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Brown ZJ, Shannon AH, Cloyd JM. Neoadjuvant therapy for localized pancreatic ductal adenocarcinoma. Minerva Surg 2024; 79:315-325. [PMID: 38385797 DOI: 10.23736/s2724-5691.23.10150-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is a highly aggressive tumor with poor prognosis and rising incidence globally. Multimodal therapy that includes surgical resection and chemotherapy with or without radiation offers the best chance for optimal outcomes. The development of established criteria for anatomic staging of local primary tumors into potentially resectable (PR), borderline resectable (BR), and locally advanced (LA) has greatly clarified the optimal treatment strategies. While upfront surgical resection was traditionally the recommended approach for localized PDAC, increasingly neoadjuvant therapy (NT) is recommended prior to surgery. Whereas NT can lead to downstaging that facilitates surgical resection for BR/LA cancers, NT also enhances patient selection for surgery, improves margin-negative resection rates, and increases the odds of completing multimodality therapy for all patients with PDAC. Herein, we review the rationale for NT for localized PDAC and summarize existing and ongoing literature.
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Affiliation(s)
- Zachary J Brown
- Department of Surgery, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Alexander H Shannon
- Department of Surgery, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jordan M Cloyd
- Department of Surgery, Ohio State University Wexner Medical Center, Columbus, OH, USA -
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35
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Hu H, Xu Y, Zhang Q, Gao Y, Wu Z. The survival effect of neoadjuvant therapy and neoadjuvant plus adjuvant therapy on pancreatic ductal adenocarcinoma patients with different TNM stages: a propensity score matching analysis based on the SEER database. Expert Rev Anticancer Ther 2024; 24:467-476. [PMID: 38656796 DOI: 10.1080/14737140.2024.2347513] [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: 02/23/2024] [Accepted: 04/17/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Adjuvant therapy (AT) and neoadjuvant therapy (NAT) are standard treatments for pancreatic ductal adenocarcinoma (PDAC) depending on the status of the disease. However, whether AT improves survival after NAT and radical resection in all TNM stages remains unclear. RESEARCH DESIGN AND METHODS We utilized the Surveillance, Epidemiology, and End Results (SEER) database (2010-2019) for PDAC patients who underwent radical surgery and applied Pearson's chi-square test, multivariate and univariate Cox regression, Kaplan-Meier plot, Log-rank tests, and propensity score matching (PSM) for analysis. RESULTS Given PSM after enrolling 13,868 PDAC patients, significant differences in survival were identified between AT and neoadjuvant therapy plus adjuvant therapy (NATAT) (p = 0.023) as well as between NAT and NATAT (p < 0.001). According to the AJCC 8th TNM stage, a survival advantage associated with NATAT was exclusively observed in stage III and IV disease, except for T4N0M0. Some stage IV patients receiving NATAT exhibited comparable survival to their counterparts without metastasis. CONCLUSIONS In this retrospective cohort study, we demonstrated that patients harboring tumors in late TNM stages, including N2 resectable PDAC, might have better survival from NATAT, and that certain patients with M1 disease might still benefit from comprehensive systemic therapy and radical resection.
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Affiliation(s)
- Hao Hu
- Department of Hepatobiliary Surgery, Aerospace Center Hospital, Beijing, China
| | - Yang Xu
- Department of Hepatobiliary Surgery, Aerospace Center Hospital, Beijing, China
| | - Qiang Zhang
- Department of Hepatobiliary Surgery, Aerospace Center Hospital, Beijing, China
| | - Yuan Gao
- Department of Hepatobiliary Surgery, Aerospace Center Hospital, Beijing, China
| | - Zhenyu Wu
- Department of Hepatobiliary Surgery, Aerospace Center Hospital, Beijing, China
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Mahmood U, Carrier E, Khan K. Neoadjuvant management of locally advanced pancreatic ductal adenocarcinoma - Heading towards a promising change in treatment paradigm. Cancer Treat Rev 2024; 127:102750. [PMID: 38703592 DOI: 10.1016/j.ctrv.2024.102750] [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: 04/01/2024] [Revised: 04/27/2024] [Accepted: 04/29/2024] [Indexed: 05/06/2024]
Abstract
Traditional chemotherapy-based adjuvant therapies for locally advanced pancreatic ductal adenocarcinoma (PDAC) have been associated with poor clinical outcomes driven partly by its complex anatomy and molecular heterogeneity. Treatment for PDAC is challenged by presence of a dense tumour microenvironment involving an interplay of multiple tumoural and stromal components which promote metastatic oncogenic behaviour. PDAC also involves aberrations in multiple signalling pathways with paucity of treatment options against the most common mutations including KRAS, TP53, CDKN2A andSMAD4. However, recent discovery of new mechanisms implicated in pancreatic carcinogenesis have led to identification of promising mechanistic therapeutic targets such as NET1 and ULK1. Early evidence also suggests the utility of targeting multiple DNA repair processes, modulators of DNA replication and major DNA damage response regulators. We explore the clinical rationale behind a neoadjuvant therapeutic strategy and emerging predictors of survival benefit associated with this approach. We also discuss challenges and opportunities originating from recent clinical trials evaluating neoadjuvant treatments composed of various combinations of radiotherapy, chemotherapy and immunotherapeutic regimens that have aimed to address some of these biological challenges. Selective treatment of patients harbouring specific genomic aberrations with targeted agents and immunotherapy can translate into optimum survival outcomes in PDAC. We also share perspectives on emerging prospective clinical evidence regarding stromal modifying agents, such as Tumour Growth Factor-Beta and Connective Tissue Growth Factor inhibitors along with novel vaccination-based approaches in improving PDAC outcomes.
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Affiliation(s)
- Umair Mahmood
- Department of Gastrointestinal Oncology, University College Hospital NHS Foundation Trust (UCLH), London NW1 2BU, UK
| | - Ewa Carrier
- Department of Clinical Development, FibroGen, Inc., San Francisco, CA, USA
| | - Khurum Khan
- Department of Gastrointestinal Oncology, University College Hospital NHS Foundation Trust (UCLH), London NW1 2BU, UK; University College London Cancer Institute, London WC1E 6DD, UK.
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Safyan RA, Kim E, Dekker E, Homs M, Aguirre AJ, Koerkamp BG, Chiorean EG. Multidisciplinary Standards and Evolving Therapies for Patients With Pancreatic Cancer. Am Soc Clin Oncol Educ Book 2024; 44:e438598. [PMID: 38781541 DOI: 10.1200/edbk_438598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Pancreatic ductal adenocarcinoma (PDA) is a challenging disease that presents at an advanced stage and results in many symptoms that negatively influence patients' quality of life and reduce their ability to receive effective treatment. Early implementation of expert multidisciplinary care with nutritional support, exercise, and palliative care for both early-stage and advanced disease promises to maintain or improve the patients' physical, social, and psychological well-being, decrease aggressive interventions at the end of life, and ultimately improve survival. Moreover, advances in treatment strategies in the neoadjuvant and metastatic setting combined with novel therapeutic agents targeting the key drivers of the disease are leading to improvements in the care of patients with pancreatic cancer. Here, we emphasize the multidisciplinary supportive and therapeutic care of patients with PDA, review current guidelines and new developments of neoadjuvant and perioperative treatments for localized disease, as well as the treatment standards and the evolving field of precision oncology and immunotherapies for advanced PDA.
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Affiliation(s)
- Rachael A Safyan
- University of Washington School of Medicine, Department of Medicine, Division of Hematology-Oncology, Seattle, WA
- Fred Hutchinson Cancer Center, Clinical Research Division, Seattle, WA
| | - Eejung Kim
- Dana-Farber Cancer Center, Department of Medical Oncology, Boston, MA
- Harvard Medical School, Boston, MA
| | - Emmelie Dekker
- Erasmus MC Cancer Institute, Department of Surgery, Rotterdam, the Netherlands
| | - Marjolein Homs
- Erasmus MC Cancer Institute, Department of Medical Oncology, Rotterdam, the Netherlands
| | - Andrew J Aguirre
- Dana-Farber Cancer Center, Department of Medical Oncology, Boston, MA
- Harvard Medical School, Boston, MA
| | - Bas Groot Koerkamp
- Erasmus MC Cancer Institute, Department of Surgery, Rotterdam, the Netherlands
| | - E Gabriela Chiorean
- University of Washington School of Medicine, Department of Medicine, Division of Hematology-Oncology, Seattle, WA
- Fred Hutchinson Cancer Center, Clinical Research Division, Seattle, WA
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Petrikowski M, Fahlbusch T, Reinacher-Schick A, Kucinskaite G, Tannapfel A, Uhl W, Belyaev O. Impact of preoperative chemotherapy on surgical results in 139 patients with locally advanced pancreatic cancer. Hepatobiliary Surg Nutr 2024; 13:460-471. [PMID: 38911210 PMCID: PMC11190532 DOI: 10.21037/hbsn-23-426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 12/14/2023] [Indexed: 06/25/2024]
Abstract
Background The establishment of preoperative chemotherapy (PCT) with FOLFIRINOX and gemcitabine/nab-paclitaxel in recent years has enabled resectability in many patients with initially locally advanced pancreatic cancer (LAPC). Nevertheless, information about the impact of PCT on surgical results is scarce. Methods All patients with initial LAPC who received surgery after chemotherapy at the high-volume centre for pancreatic surgery of St. Josef-Hospital Bochum between 2015 and 2022 were included in this retrospective cohort analysis. Results A total of 139 patients underwent surgery after pre-treatment with FOLFIRINOX (76.3%), gemcitabine/nab-paclitaxel (11.5%), both (5.8%) and other regimens (6.5%). Eighty-five tumors (61.2%) were resectable after PCT. R0 resection was achieved in 92.9%, R1 in 7.1% and R2 in 0% of cases. Fifty-four tumors were still not resectable at the time of surgery. Surgical results of the patients did not show increased postoperative mortality and morbidity compared to the literature data. Postoperative 30-day mortality was 1.4%. Rates for pancreas-specific complications [postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH), and others] were not increased. POPF occurred in 10.5% and DGE in 26.3% after pancreaticoduodenectomy. After distal pancreatectomy, POPF was detected in 37.5% and DGE in 12.5%. Median postoperative survival (31 vs. 13 months) and overall survival after initial diagnosis (40 vs. 20 months) were significantly longer in resected patients (P<0.001). Postoperative recurrence-free survival in resected patients amounted to 12 months. Conclusions This study underlines that PCT allows resectability of primarily unresectable patients with LAPC without increasing perioperative mortality and morbidity. It may lead to a significant prolongation of recurrence-free and overall survival in resected patients after PCT.
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Affiliation(s)
- Marvin Petrikowski
- Department of General and Visceral Surgery, St. Josef-Hospital Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Tim Fahlbusch
- Department of General and Visceral Surgery, St. Josef-Hospital Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Anke Reinacher-Schick
- Department of Hematology and Oncology with Palliative Medicine, St. Josef-Hospital Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Giedre Kucinskaite
- Department of Radiology and Nuclear Medicine, St. Josef-Hospital Bochum, Ruhr-University Bochum, Bochum, Germany
| | | | - Waldemar Uhl
- Department of General and Visceral Surgery, St. Josef-Hospital Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Orlin Belyaev
- Department of General and Visceral Surgery, St. Josef-Hospital Bochum, Ruhr-University Bochum, Bochum, Germany
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Zohar N, Kowal L, Moskal D, Ponzini F, Sun G, Lamm RJ, Williamson J, Nevler A, Lavu H, Maley WR, Yeo CJ, Bowne WB. Contemporary report of surgical outcomes after single-stage total pancreatectomy: A 10-year experience. J Surg Oncol 2024; 129:1235-1244. [PMID: 38419193 DOI: 10.1002/jso.27614] [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: 10/20/2023] [Revised: 01/25/2024] [Accepted: 02/11/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Surgeons rarely perform elective total pancreatectomy (TP). Our study seeks to report surgical outcomes in a contemporary series of single-stage (SS) TP patients. METHODS Between the years 2013 to 2023 we conducted a retrospective review of 60 consecutive patients who underwent SSTP. Demographics, pathology, treatment-related variables, and survival were recorded and analyzed. RESULTS SSTP consisted of 3% (60/1859) of elective pancreas resections conducted. Patient median age was 68 years. Ninety percent of these patients (n = 54) underwent SSTP for pancreatic ductal adenocarcinoma (PDAC). Conversion from a planned partial pancreatectomy to TP occurred intraoperatively in 31 (52%) patients. Fifty-nine patients (98%) underwent an R0 resection. Median length of hospital stay was 6 days. The majority of morbidities were minor, with 27% patients (n = 16) developing severe complications (Clavien-Dindo ≥3). Thirty and ninety-day mortality rates were 1.67% (one patient) and 5% (three patients), respectively. Median survival for the entire cohort was 24.4 months; 22.7 months for PDAC patients, with 1-, 3-, and 5-year survival of 68%, 43%, and 16%, respectively. No mortality occurred in non-PDAC patients (n = 6). CONCLUSION Elective single-stage total pancreatectomy can be a safe and appropriate treatment option. SSTP should be in the armamentarium of surgeons performing pancreatic resection.
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Affiliation(s)
- Nitzan Zohar
- Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Luke Kowal
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - David Moskal
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Francesca Ponzini
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - George Sun
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ryan J Lamm
- Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - John Williamson
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Avinoam Nevler
- Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Harish Lavu
- Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Warren R Maley
- Department of Surgery, Jefferson Transplant Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Charles J Yeo
- Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Wilbur B Bowne
- Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Goetze TO, Reichart A, Bankstahl US, Pauligk C, Loose M, Kraus TW, Elshafei M, Bechstein WO, Trojan J, Behrend M, Homann N, Venerito M, Bohle W, Varvenne M, Bolling C, Behringer DM, Kratz-Albers K, Siegler GM, Hozaeel W, Al-Batran SE. Adjuvant Gemcitabine Versus Neoadjuvant/Adjuvant FOLFIRINOX in Resectable Pancreatic Cancer: The Randomized Multicenter Phase II NEPAFOX Trial. Ann Surg Oncol 2024; 31:4073-4083. [PMID: 38459418 PMCID: PMC11076394 DOI: 10.1245/s10434-024-15011-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 01/21/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Although addition of adjuvant chemotherapy is the current standard, the prognosis of pancreatic cancers still remains poor. The NEPAFOX trial evaluated perioperative treatment with FOLFIRINOX in resectable pancreatic cancer. PATIENTS AND METHODS This multicenter phase II trial randomized patients with resectable or borderline resectable pancreatic cancer without metastases into arm (A,) upfront surgery plus adjuvant gemcitabine, or arm (B,) perioperative FOLFIRINOX. The primary endpoint was overall survival (OS). RESULTS Owing to poor accrual, recruitment was prematurely stopped after randomization of 40 of the planned 126 patients (A: 21, B: 19). Overall, approximately three-quarters were classified as primarily resectable (A: 16, B: 15), and the remaining patients were classified as borderline resectable (A: 5, B: 4). Of the 12 evaluable patients, 3 achieved partial response under neoadjuvant FOLFIRINOX. Of the 21 patients in arm A and 19 patients in arm B, 17 and 7 underwent curative surgery, and R0-resection was achieved in 77% and 71%, respectively. Perioperative morbidity occurred in 72% in arm A and 46% in arm B, whereas non-surgical toxicity was comparable in both arms. Median RFS/PFS was almost doubled in arm B (14.1 months) compared with arm A (8.4 months) in the population with surgical resection, whereas median OS was comparable between both arms. CONCLUSIONS Although the analysis was only descriptive owing to small patient numbers, no safety issues regarding surgical complications were observed in the perioperative FOLFIRINOX arm. Thus, considering the small number of patients, perioperative treatment approach appears feasible and potentially effective in well-selected cohorts of patients. In pancreatic cancer, patient selection before initiation of neoadjuvant therapy appears to be critical.
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Affiliation(s)
- Thorsten O Goetze
- Krankenhaus Nordwest, Institut für Klinisch Onkologische Forschchung IKF, University Cancer Center (UCT) Frankfurt, Frankfurt, Germany.
- University Cancer Center (UCT) Frankfurt, Goethe Universität, Frankfurt, Germany.
- Frankfurter Institut für Klinische Krebsforschung IKF am Krankenhaus Nordwest, Frankfurt, Germany.
| | - Alexander Reichart
- Krankenhaus Nordwest, Institut für Klinisch Onkologische Forschchung IKF, University Cancer Center (UCT) Frankfurt, Frankfurt, Germany
| | - Ulli S Bankstahl
- Krankenhaus Nordwest, Institut für Klinisch Onkologische Forschchung IKF, University Cancer Center (UCT) Frankfurt, Frankfurt, Germany
| | - Claudia Pauligk
- Frankfurter Institut für Klinische Krebsforschung IKF am Krankenhaus Nordwest, Frankfurt, Germany
| | - Maria Loose
- Frankfurter Institut für Klinische Krebsforschung IKF am Krankenhaus Nordwest, Frankfurt, Germany
| | - Thomas W Kraus
- Krankenhaus Nordwest, Allgemein-, Viszeral- und Minimal Invasive Chirurgie, Frankfurt, Germany
| | - Moustafa Elshafei
- Krankenhaus Nordwest, Allgemein-, Viszeral- und Minimal Invasive Chirurgie, Frankfurt, Germany
| | - Wolf O Bechstein
- Klinik für Allgemein-, Viszeral-, Transplantations- und Thoraxchirurgie, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - Jörg Trojan
- Gastrointestinale Onkologie, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - Matthias Behrend
- Viszeral-, Thorax- und Gefäßchirurgie, DONAUISAR Klinikum Deggendorf, Deggendorf, Germany
| | - Nils Homann
- Medizinische Klinik II, Klinikum Wolfsburg, Wolfsburg, Germany
| | - Marino Venerito
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Magdeburg, Magdeburg, Germany
| | - Wolfram Bohle
- Klinik für Gastroenterologie, Gastroenterologische Onkologie, Klinikum Stuttgart, Stuttgart, Germany
- Hepatologie, Infektiologie und Pneumologie, Stuttgart, Germany
| | | | - Claus Bolling
- Hämatologie/Onkologie, Agaplesion Markus Krankenhaus, Frankfurt, Germany
| | - Dirk M Behringer
- Klinik für Hämatologie, Onkologie und Palliativmedizin, Augusta-Kranken-Anstalt Bochum, Bochum, Germany
| | | | - Gabriele M Siegler
- Klinikum Nürnberg Nord/Paracelsus Medizinische Privatuniversität, Medizinische Klinik, Hämatologie/Onkologie, Nürnberg, Germany
| | - Wael Hozaeel
- Krankenhaus Nordwest, Institut für Klinisch Onkologische Forschchung IKF, University Cancer Center (UCT) Frankfurt, Frankfurt, Germany
| | - Salah-Eddin Al-Batran
- Krankenhaus Nordwest, Institut für Klinisch Onkologische Forschchung IKF, University Cancer Center (UCT) Frankfurt, Frankfurt, Germany
- University Cancer Center (UCT) Frankfurt, Goethe Universität, Frankfurt, Germany
- Frankfurter Institut für Klinische Krebsforschung IKF am Krankenhaus Nordwest, Frankfurt, Germany
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41
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Liu M, Wei AC. Advances in Surgery and (Neo) Adjuvant Therapy in the Management of Pancreatic Cancer. Hematol Oncol Clin North Am 2024; 38:629-642. [PMID: 38429197 DOI: 10.1016/j.hoc.2024.01.004] [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: 03/03/2024]
Abstract
A multimodality approach, which usually includes chemotherapy, surgery, and/or radiotherapy, is optimal for patients with localized pancreatic cancer. The timing and sequence of these interventions depend on anatomic resectability and the biological suitability of the tumor and the patient. Tumors with vascular involvement (ie, borderline resectable/locally advanced) require surgical reassessments after therapy and participation of surgeons familiar with advanced techniques. When indicated, venous reconstruction should be offered as standard of care because it has acceptable morbidity. Morbidity and mortality of pancreas surgery may be mitigated when surgery is performed at high-volume centers.
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Affiliation(s)
- Mengyuan Liu
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Alice C Wei
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
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Haberkorn BCM, Hoogendijk L, Loosveld OS, Thijs AMJ, Verstijnen J. Real Life Data and Outcome of FOLFIRINOX Use in Metastatic Pancreatic Cancer Patients in General Hospitals in the Netherlands. J Gastrointest Cancer 2024; 55:838-844. [PMID: 38319559 DOI: 10.1007/s12029-023-01006-2] [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] [Accepted: 12/21/2023] [Indexed: 02/07/2024]
Abstract
INTRODUCTION Pancreatic cancer is one of the five most common causes of cancer mortality in developed countries. In patients with metastatic disease, the most frequent treatment used is FOLFIRINOX, which is associated with moderate toxicity which could influence quality of life. The efficacy of FOLFIRINOX in a general population in the Netherlands has not been subject of research before, and therefore, this research has been set up in order to investigate what the real-life benefits of FOLFIRINOX are in a population with metastatic pancreatic cancer (mPC) treated in three general hospitals in the Netherlands. METHODS The data used in this study was collected by patient records leading to a noninterventional retrospective cohort study. Eighty-six patients, over 18 years of age, diagnosed with mPC between the years 2015 and 2022 and treated with FOLFIRINOX at Maasstad Hospital in Rotterdam, Amphia Hospital in Breda, or Catharina Hospital in Eindhoven, were included in the study. Kaplan-Meier models were used in order to represent survival outcomes. RESULTS The results showed a median overall survival of 228 days (IQR 118-355). Only 14.0% (n = 12) completed the first-line treatment, and 51.2% (n = 44) of patients stopped treatment before or during cycle 6. Toxicity is highest, grade 3, after the first cycle but remains high for grade 1 and 2 during all treatment cycles. CONCLUSION Survival rates for patient with metastatic pancreatic cancer treated with FOLFIRINOX were worse in our study population than in comparative studies.
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Affiliation(s)
- B C M Haberkorn
- Department of Medical Oncology, Maasstad Ziekenhuis Rotterdam, Maasstadweg 21, 3079 DZ, Rotterdam, the Netherlands.
| | | | - O S Loosveld
- Department of Medical Oncology, Amphia Ziekenhuis Breda, Breda, Netherlands
| | - A M J Thijs
- Department of Medical Oncology, Catharina Ziekenhuis Eindhoven, Eindhoven, Netherlands
| | - J Verstijnen
- Department of Medical Oncology, Maasstad Ziekenhuis Rotterdam, Maasstadweg 21, 3079 DZ, Rotterdam, the Netherlands
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43
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Moten AS. Fibrosis following neoadjuvant treatment of PDAC: Less is not always more. Am J Surg 2024; 232:8. [PMID: 38092641 DOI: 10.1016/j.amjsurg.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 12/01/2023] [Indexed: 05/15/2024]
Affiliation(s)
- Ambria S Moten
- Surgical Oncology, Complex Upper GI/HPB Surgery, Packnett Family Cancer Institute, Parkview Health, 11050 Parkview Circle, Fort Wayne, IN, USA.
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44
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Yamada S, Hashimoto D, Yamamoto T, Yamaki S, Oshima K, Murotani K, Sekimoto M, Nakao A, Satoi S. Reconsideration of the clinical impact of neoadjuvant therapy in resectable and borderline resectable pancreatic cancer: A dual-institution collaborative clinical study. Pancreatology 2024; 24:592-599. [PMID: 38548551 DOI: 10.1016/j.pan.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 03/05/2024] [Accepted: 03/23/2024] [Indexed: 06/12/2024]
Abstract
PURPOSE We investigated true indication of neoadjuvant therapy (NAT) in resectable pancreatic cancer and the optimal surgical timing in borderline resectable pancreatic cancer. METHODS A total of 687 patients with resectable or borderline resectable pancreatic cancer were enrolled. Survival analysis was performed by intention-to-treat analysis and propensity score matching (PSM) was conducted. RESULTS In resectable disease, the NAT group showed better overall survival (OS) compared with the upfront group. Multivariate analysis identified CA19-9 level (≥100 U/mL) and lymph node metastasis to be prognostic factors, and a tumor size of 25 mm was the optimal cut-off value to predict lymph node metastasis. There was no significant survival difference between patients with a tumor size ≤25 mm and CA19-9 < 100 U/mL and those in the NAT group. In borderline resectable disease, OS in the NAT group was significantly better than that in the upfront group. CEA (≥5 ng/mL) and CA19-9 (≥100 U/mL) were identified as prognostic factors; however, the OS of patients fulfilling these factors was worse than that of the NAT group. CONCLUSIONS NAT could be unnecessary in patients with tumor size ≤25 mm and CA19-9 < 100 U/mL in resectable disease. In borderline resectable disease, surgery should be delayed until tumor marker levels are well controlled.
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Affiliation(s)
- Suguru Yamada
- Department of Gastroenterological Surgery, Nagoya Central Hospital, Japan
| | | | | | - So Yamaki
- Department of Surgery, Kansai Medical University, Japan
| | - Kenji Oshima
- Department of Gastroenterological Surgery, Nagoya Central Hospital, Japan
| | - Kenta Murotani
- Biostatistics Center, Graduate School of Medicine, Kurume University, Japan
| | - Mitsugu Sekimoto
- Division of Surgical Oncology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Akimasa Nakao
- Department of Gastroenterological Surgery, Nagoya Central Hospital, Japan
| | - Sohei Satoi
- Department of Surgery, Kansai Medical University, Japan; Division of Surgical Oncology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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45
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He J, Lv N, Yang Z, Luo Y, Zhong W, Wu C. Comparing upfront surgery with neoadjuvant treatments in patients with resectable, borderline resectable or locally advanced pancreatic cancer: a systematic review and network meta-analysis of randomized clinical trials. Int J Surg 2024; 110:3900-3909. [PMID: 38935819 PMCID: PMC11175811 DOI: 10.1097/js9.0000000000001313] [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: 11/02/2023] [Accepted: 02/25/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND The aim was to explore the optimal neoadjuvant therapy strategy for resectable, borderline resectable, and locally advanced pancreatic cancer, in order to provide a theoretical basis for the development of new neoadjuvant treatment protocols for clinical use. PATIENTS AND METHODS The authors reviewed literature titles and abstracts comparing three treatment strategies (neoadjuvant chemoradiotherapy, neoadjuvant chemotherapy, and upfront surgery) in PubMed, Embase, The Cochrane Library, Web of Science from 2009 to 2023 to estimate relative odds ratios for resection rate and hazard ratios (HRs) for overall survival (OS) in all include trials. RESULTS A total of nine studies involving 889 patients were included in the analysis. The treatment methods included upfront surgery, neoadjuvant chemotherapy, and neoadjuvant chemoradiotherapy followed by surgery. The network meta-analysis results demonstrated that neoadjuvant chemoradiotherapy followed by surgery was an effective approach in improving OS for resectable and borderline resectable pancreatic cancer (RPC) patients compared to upfront surgery (HR: 0.79, 95% CI: 0.64-0.98) and neoadjuvant chemotherapy (HR: 0.79, 95% CI: 0.64-0.98). Additionally, neoadjuvant chemoradiotherapy significantly increased the margin negative resection (R0) rate and pathological negative lymph node (pN0) rate in patients with resectable and borderline RPC. However, it is worth noting that neoadjuvant chemoradiotherapy increased the risk of grade 3 or higher treatment-related adverse events, including in patients with locally advanced pancreatic cancer. CONCLUSIONS The current evidence suggests that neoadjuvant chemoradiotherapy followed by surgery is the optimal choice for treating patients with resectable and borderline RPC. Future research should focus on optimizing neoadjuvant chemoradiotherapy regimens to effectively improve OS while reducing the occurrence of adverse events.
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Affiliation(s)
| | | | | | | | | | - Chunli Wu
- Department of Radiation Oncology, The Fourth Affiliated Hospital of China Medical University, Liaoning, China
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46
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Wismans LV, Suurmeijer JA, van Dongen JC, Bonsing BA, Van Santvoort HC, Wilmink JW, van Tienhoven G, de Hingh IH, Lips DJ, van der Harst E, de Meijer VE, Patijn GA, Bosscha K, Stommel MW, Festen S, den Dulk M, Nuyttens JJ, Intven MPW, de Vos-Geelen J, Molenaar IQ, Busch OR, Koerkamp BG, Besselink MG, van Eijck CHJ. Preoperative chemoradiotherapy but not chemotherapy is associated with reduced risk of postoperative pancreatic fistula after pancreatoduodenectomy for pancreatic ductal adenocarcinoma: a nationwide analysis. Surgery 2024; 175:1580-1586. [PMID: 38448277 DOI: 10.1016/j.surg.2024.01.029] [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: 06/29/2023] [Revised: 12/01/2023] [Accepted: 01/21/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Postoperative pancreatic fistula remains the leading cause of significant morbidity after pancreatoduodenectomy for pancreatic ductal adenocarcinoma. Preoperative chemoradiotherapy has been described to reduce the risk of postoperative pancreatic fistula, but randomized trials on neoadjuvant treatment in pancreatic ductal adenocarcinoma focus increasingly on preoperative chemotherapy rather than preoperative chemoradiotherapy. This study aimed to investigate the impact of preoperative chemotherapy and preoperative chemoradiotherapy on postoperative pancreatic fistula and other pancreatic-specific surgery related complications on a nationwide level. METHODS All patients after pancreatoduodenectomy for pancreatic ductal adenocarcinoma were included in the mandatory nationwide prospective Dutch Pancreatic Cancer Audit (2014-2020). Baseline and treatment characteristics were compared between immediate surgery, preoperative chemotherapy, and preoperative chemoradiotherapy. The relationship between preoperative chemotherapy, chemoradiotherapy, and clinically relevant postoperative pancreatic fistula (International Study Group of Pancreatic Surgery grade B/C) was investigated using multivariable logistic regression analyses. RESULTS Overall, 2,019 patients after pancreatoduodenectomy for pancreatic ductal adenocarcinoma were included, of whom 1,678 underwent immediate surgery (83.1%), 192 (9.5%) received preoperative chemotherapy, and 149 (7.4%) received preoperative chemoradiotherapy. Postoperative pancreatic fistula occurred in 8.3% of patients after immediate surgery, 4.2% after preoperative chemotherapy, and 2.0% after preoperative chemoradiotherapy (P = .004). In multivariable analysis, the use of preoperative chemoradiotherapy was associated with reduced risk of postoperative pancreatic fistula (odds ratio, 0.21; 95% confidence interval, 0.03-0.69; P = .033) compared with immediate surgery, whereas preoperative chemotherapy was not (odds ratio, 0.59; 95% confidence interval, 0.25-1.25; P = .199). Intraoperatively hard, or fibrotic pancreatic texture was most frequently observed after preoperative chemoradiotherapy (53% immediate surgery, 62% preoperative chemotherapy, 77% preoperative chemoradiotherapy, P < .001). CONCLUSION This nationwide analysis demonstrated that in patients undergoing pancreatoduodenectomy for pancreatic ductal adenocarcinoma, only preoperative chemoradiotherapy, but not preoperative chemotherapy, was associated with a reduced risk of postoperative pancreatic fistula.
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Affiliation(s)
- Leonoor V Wismans
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - J Annelie Suurmeijer
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | - Jelle C van Dongen
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, the Netherlands
| | - Hjalmar C Van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein, the Netherlands
| | - Johanna W Wilmink
- Cancer Center Amsterdam, the Netherlands; Department of Medical Oncology, Amsterdam UMC, location University of Amsterdam, the Netherlands
| | - Geertjan van Tienhoven
- Cancer Center Amsterdam, the Netherlands; Department of Radiation Oncology, Amsterdam UMC, location University of Amsterdam, the Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | | | - Vincent E de Meijer
- Department of Surgery, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala Clinics, Zwolle, the Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Ziekenhuis, Den Bosch, the Netherlands
| | - Martijn W Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Center, the Netherlands
| | - Joost J Nuyttens
- Department of Radiation Oncology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Martijn P W Intven
- Department of Radiation Oncology, University Medical Center Utrecht, the Netherlands
| | - Judith de Vos-Geelen
- Department of Medical Oncology, Maastricht University Medical Center, the Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands. http://www.twitter.com/MarcBesselink
| | - Casper H J van Eijck
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands.
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Akumuo RC, Villano AM, Reddy SP, Devarajan K, Barrak D, Reddy SS. Type of neoadjuvant treatment strategy is associated with differential pathologic responses in pancreatic ductal adenocarcinoma. Am J Surg 2024; 232:9-14. [PMID: 37977978 DOI: 10.1016/j.amjsurg.2023.10.053] [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: 08/27/2023] [Revised: 10/21/2023] [Accepted: 10/30/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Tumor fibrosis after neoadjuvant treatment (NAT) for pancreatic ductal adenocarcinoma (PDAC) correlates with treatment response. Herein we assessed how different NAT strategies influence pathologic responses and survival. METHODS Patients with surgically resected PDAC who received NAT (1991-2020) were included. Descriptive statistics compared outcomes amongst fibrosis groups (none, minor <50 %, partial 51%-94 %, major ≥95 %) and NAT (chemotherapy alone, chemoradiation, or chemotherapy + chemoradiation (total neoadjuvant therapy, TNT)). RESULTS Patients with major fibrosis most often received TNT (65.8 %, p < 0.001). Major fibrosis was associated with the greatest rate of downstaging (77.8 %, p < 0.001), highest R0 margin rate (100 %, p < 0.01), and lowest mean positive lymph node ratio (0.80, p < 0.01). Amongst complete responders, 11/14 (78.6 %) received TNT. Median overall (66.3 months, p = 0.003) and disease-free (54.7months, p = 0.05) survival were highest with major fibrosis. CONCLUSIONS Major fibrosis and complete pathologic responses after NAT are most frequent with a TNT strategy and are associated with improved outcomes.
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Affiliation(s)
- Rita C Akumuo
- Department of Surgery, Temple University Hospital, Philadelphia, PA, USA; Division of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.
| | - Anthony M Villano
- Division of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.
| | - Sai P Reddy
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA.
| | - Karthik Devarajan
- Department of Biostatistics and Bioinformatics, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Dany Barrak
- Division of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.
| | - Sanjay S Reddy
- Division of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.
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Su YY, Chiang NJ, Chiu TJ, Huang CJ, Hsu SJ, Lin HC, Yang SH, Yang Y, Chou WC, Chen YY, Bai LY, Li CP, Chen JS. Systemic treatments in pancreatic cancer: Taiwan pancreas society recommendation. Biomed J 2024; 47:100696. [PMID: 38169173 PMCID: PMC11332987 DOI: 10.1016/j.bj.2023.100696] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/05/2023] [Accepted: 12/23/2023] [Indexed: 01/05/2024] Open
Abstract
Pancreatic cancer is a highly aggressive malignancy with a poor prognosis. Over the past decade, significant therapeutic advancements have improved the survival rates of patients with pancreatic cancer. One of the primary factors contributing to these positive outcomes is the evolution of chemotherapy, from monotherapy to doublet or triplet regimens, and the integration of multimodal approaches. Additionally, targeted agents tailored to patients with specific genetic alterations and the development of cell therapies show promise in benefiting certain subpopulations. This article focuses on examining pivotal studies that explore the role of chemotherapy in neoadjuvant, adjuvant, maintenance, and salvage settings; highlights interesting findings related to cell therapy; and provides an overview of ongoing trials concerning metastatic settings. This review primarily aimed to offer recommendations based on therapeutic evidence, recent advancements in new treatment combinations, and the most innovative approaches. A unique aspect of this review is the inclusion of published papers on clinical trials and real-world data in Taiwan, thus adding a valuable perspective to the overall analysis.
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Affiliation(s)
- Yung-Yeh Su
- National Institute of Cancer Research, National Health Research Institutes, Tainan, Taiwan; Department of Oncology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Internal Medicine, Kaohsiung Medical University Hospital, and Center for Cancer Research, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Nai-Jung Chiang
- National Institute of Cancer Research, National Health Research Institutes, Tainan, Taiwan; Department of Oncology, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Therapeutic and Research Center of Pancreatic Cancer, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Tai-Jan Chiu
- Division of Hematology-Oncology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chien-Jui Huang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Shao-Jung Hsu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Therapeutic and Research Center of Pancreatic Cancer, Taipei Veterans General Hospital, Taipei, Taiwan; Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsin-Chen Lin
- Division of Medical Oncology, Department of Oncology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shih-Hung Yang
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Youngsen Yang
- Division of Cancer Prevention and Control, Department of Oncology, Taichung Veterans General Hospital, Taichung, Taiwan; College of Medicine, School of Medicine, China Medical University, Taichung, Taiwan
| | - Wen-Chi Chou
- Chang Gung University College of Medicine, Taoyuan, Taiwan; Department of Hematology-Oncology, Linkou Chang Gung Memorial Hospital, Taiwan
| | - Yen-Yang Chen
- Division of Hematology-Oncology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Li-Yuan Bai
- College of Medicine, School of Medicine, China Medical University, Taichung, Taiwan; Division of Hematology and Oncology, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Chung-Pin Li
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Therapeutic and Research Center of Pancreatic Cancer, Taipei Veterans General Hospital, Taipei, Taiwan; Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Division of Clinical Skills Training, Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan.
| | - Jen-Shi Chen
- Chang Gung University College of Medicine, Taoyuan, Taiwan; Department of Hematology-Oncology, Linkou Chang Gung Memorial Hospital, Taiwan.
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Waugh E, Glinka J, Breadner D, Liu R, Tang E, Allen L, Welch S, Leslie K, Skaro A. Survival benefit of neoadjuvant FOLFIRINOX for patients with borderline resectable pancreatic cancer. Ann Hepatobiliary Pancreat Surg 2024; 28:229-237. [PMID: 38296221 PMCID: PMC11128787 DOI: 10.14701/ahbps.23-107] [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: 09/14/2023] [Revised: 12/05/2023] [Accepted: 12/09/2023] [Indexed: 05/25/2024] Open
Abstract
Backgrounds/Aims While patients with borderline resectable pancreatic cancer (BRPC) are a target population for neoadjuvant chemotherapy (NAC), formal guidelines for neoadjuvant therapy are lacking. We assessed the perioperative and oncological outcomes in patients with BRPC undergoing NAC with FOLFIRINOX for patients undergoing upfront surgery (US). Methods The AHPBA criteria for borderline resectability and/or a CA19-9 level > 100 μ/mL defined borderline resectable tumors retrieved from a prospectively populated institutional registry from 2007 to 2020. The primary outcome was overall survival (OS) at 1 and 3 years. A Cox Proportional Hazard model based on intention to treat was used. A receiver-operator characteristics (ROC) curve was constructed to assess the discriminatory capability of the use of CA19-9 > 100 μ/mL to predict resectability and mortality. Results Forty BRPC patients underwent NAC, while 46 underwent US. The median OS with NAC was 19.8 months (interquartile range [IQR], 10.3-44.24) vs. 10.6 months (IQR, 6.37-17.6) with US. At 1 year, 70% of the NAC group and 41.3% of the US group survived (p = 0.008). At 3 years, 42.5 % of the NAC group and 10.9% of the US group survived (p = 0.001). NAC significantly reduced the hazard of death (adjusted hazard ratio, 0.20; 95% confidence interval, 0.07-0.54; p = 0.001). CA19-9 > 100 μ/mL showed poor discrimination in predicting mortality, but was a moderate predictor of resectability. Conclusions We found a survival benefit of NAC with FOLFIRINOX for BRPC. Greater pre-treatment of CA19-9 and multivessel involvement on initial imaging were associated with progression of the disease following NAC.
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Affiliation(s)
- Evelyn Waugh
- Division of General Surgery, Department of Surgery, Western University, London, ON, Canada
| | - Juan Glinka
- Division of General Surgery, Department of Surgery, Western University, London, ON, Canada
| | - Daniel Breadner
- Division of Medical Oncology, Department of Oncology, Western University, London, ON, Canada
| | - Rachel Liu
- Division of General Surgery, Department of Surgery, Western University, London, ON, Canada
| | - Ephraim Tang
- Division of General Surgery, Department of Surgery, Western University, London, ON, Canada
| | - Laura Allen
- Division of General Surgery, Department of Surgery, Western University, London, ON, Canada
| | - Stephen Welch
- Division of Medical Oncology, Department of Oncology, Western University, London, ON, Canada
| | - Ken Leslie
- Division of General Surgery, Department of Surgery, Western University, London, ON, Canada
| | - Anton Skaro
- Division of General Surgery, Department of Surgery, Western University, London, ON, Canada
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Göhrig A, Hilfenhaus G, Rosseck F, Welzel M, Moser B, Barbone G, Kunze CA, Rein J, Wilken G, Böhmig M, Malinka T, Tacke F, Bahra M, Detjen KM, Fischer C. Placental growth factor promotes neural invasion and predicts disease prognosis in resectable pancreatic cancer. J Exp Clin Cancer Res 2024; 43:153. [PMID: 38816706 PMCID: PMC11138065 DOI: 10.1186/s13046-024-03066-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 05/09/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND Surgery represents the only curative treatment option for pancreatic ductal adenocarcinoma (PDAC), but recurrence in more than 85% of patients limits the success of curative-intent tumor resection. Neural invasion (NI), particularly the spread of tumor cells along nerves into extratumoral regions of the pancreas, constitutes a well-recognized risk factor for recurrence. Hence, monitoring and therapeutic targeting of NI offer the potential to stratify recurrence risk and improve recurrence-free survival. Based on the evolutionary conserved dual function of axon and vessel guidance molecules, we hypothesize that the proangiogenic vessel guidance factor placental growth factor (PlGF) fosters NI. To test this hypothesis, we correlated PlGF with NI in PDAC patient samples and functionally assessed its role for the interaction of tumor cells with nerves. METHODS Serum levels of PlGF and its soluble receptor sFlt1, and expression of PlGF mRNA transcripts in tumor tissues were determined by ELISA or qPCR in a retrospective discovery and a prospective validation cohort. Free circulating PlGF was calculated from the ratio PlGF/sFlt1. Incidence and extent of NI were quantified based on histomorphometric measurements and separately assessed for intratumoral and extratumoral nerves. PlGF function on reciprocal chemoattraction and directed neurite outgrowth was evaluated in co-cultures of PDAC cells with primary dorsal-root-ganglia neurons or Schwann cells using blocking anti-PlGF antibodies. RESULTS Elevated circulating levels of free PlGF correlated with NI and shorter overall survival in patients with PDAC qualifying for curative-intent surgery. Furthermore, high tissue PlGF mRNA transcript levels in patients undergoing curative-intent surgery correlated with a higher incidence and greater extent of NI spreading to tumor-distant extratumoral nerves. In turn, more abundant extratumoral NI predicted shorter disease-free and overall survival. Experimentally, PlGF facilitated directional and dynamic changes in neurite outgrowth of primary dorsal-root-ganglia neurons upon exposure to PDAC derived guidance and growth factors and supported mutual chemoattraction of tumor cells with neurons and Schwann cells. CONCLUSION Our translational results highlight PlGF as an axon guidance factor, which fosters neurite outgrowth and attracts tumor cells towards nerves. Hence, PlGF represents a promising circulating biomarker of NI and potential therapeutic target to improve the clinical outcome for patients with resectable PDAC.
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Affiliation(s)
- Andreas Göhrig
- Department of Hepatology & Gastroenterology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
- ECRC Experimental and Clinical Research Center, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Georg Hilfenhaus
- Department of Hematology, Oncology & Cancer Immunology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Campus Charité Mitte, Berlin, Germany
| | - Friederike Rosseck
- Institute of Pathology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Campus Charité Mitte, Berlin, Germany
| | - Martina Welzel
- Department of Hepatology & Gastroenterology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
- ECRC Experimental and Clinical Research Center, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Benjamin Moser
- Department of Hepatology & Gastroenterology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Gianluca Barbone
- Department of Hepatology & Gastroenterology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Catarina Alisa Kunze
- Institute of Pathology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Campus Charité Mitte, Berlin, Germany
| | - Johannes Rein
- Department of Pulmonology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Campus Charité Mitte, Berlin, Germany
| | - Gregor Wilken
- Department of Hepatology & Gastroenterology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Michael Böhmig
- Department of Hepatology & Gastroenterology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
- Gastroenterologie an der Krummen Lanke, Fischerhüttenstraße 109, Berlin, 14163, Germany
| | - Thomas Malinka
- Department of Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Frank Tacke
- Department of Hepatology & Gastroenterology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Marcus Bahra
- Department of Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Campus Virchow-Klinikum, Berlin, Germany
- Department of Oncological Surgery and Robotics, Waldfriede Hospital, Berlin, Germany
| | - Katharina M Detjen
- Department of Hepatology & Gastroenterology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Christian Fischer
- Department of Hepatology & Gastroenterology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany.
- ECRC Experimental and Clinical Research Center, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.
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