Preoperative chemoradiation for patients with pancreatic cancer: toxicity of endobiliary stents

Biliary Adverse Events During Neoadjuvant Therapy for Pancreatic Cancer

OBJECTIVE

To describe a high-volume experience with biliary drainage before neoadjuvant therapy (NAT) for patients with operable pancreatic cancer (PC) and characterize the association between biliary adverse events (BAEs) and patient outcome.

BACKGROUND

Patients with PC presenting with biliary obstruction require durable decompression before NAT.

METHODS

Patients with operable PC and tumor-associated biliary obstruction were examined and grouped by the presence or absence of a BAE during NAT. The incidence, timing, and management of BAEs are described, and outcomes, including the completion of all treatment and overall survival (OS), were compared.

RESULTS

Of 426 patients who received pretreatment biliary decompression, 92 (22%) experienced at least 1 BAE during NAT, and 56 (13%) required repeat intervention on their biliary stent. The median duration of NAT was 161 days for all patients and was not different in the group that experienced BAEs. The median time from initial stent placement to BAE was 64 days. An interruption in the delivery of NAT (median 7 days) occurred in 25 (6%) of 426 patients. Among 426 patients, 290 (68%) completed all NAT, including surgery: 60 (65%) of 92 patients with BAE and 230 (69%) of 334 patients without BAE ( P =0.51). Among 290 patients who completed NAT and surgery, the median OS was 39 months, 26 months for the 60 patients with BAE, and 43 months for the 230 patients without BAE ( P =0.02).

CONCLUSIONS

During extended multimodal NAT for PC, 22% of patients experienced a BAE. Although BAEs were not associated with a significant interruption of treatment, patients who experienced a BAE had worse OS.

International consensus statements for endoscopic management of distal biliary stricture

Distal biliary strictures (DBS) are common and may be caused by both malignant and benign pathologies. While endoscopic procedures play a major role in their management, a comprehensive review of the subject is still lacking. Our consensus statements were formulated by a group of expert Asian pancreatico-biliary interventional endoscopists, following a proposal from the Digestive Endoscopy Society of Taiwan, the Thai Association for Gastrointestinal Endoscopy, and the Tokyo Conference of Asian Pancreato-biliary Interventional Endoscopy. Based on a literature review utilizing Medline, Cochrane library, and Embase databases, a total of 19 consensus statements on DBS were made on diagnosis, endoscopic drainage, benign biliary stricture, malignant biliary stricture, and management of recurrent biliary obstruction and other complications. Our consensus statements provide comprehensive guidance for the endoscopic management of DBS.

Pancreatic Ductal Adenocarcinoma: Current and Evolving Therapies

Pancreatic ductal adenocarcinoma (PDAC), which constitutes 90% of pancreatic cancers, is the fourth leading cause of cancer-related deaths in the world. Due to the broad heterogeneity of genetic mutations and dense stromal environment, PDAC belongs to one of the most chemoresistant cancers. Most of the available treatments are palliative, with the objective of relieving disease-related symptoms and prolonging survival. Currently, available therapeutic options are surgery, radiation, chemotherapy, immunotherapy, and use of targeted drugs. However, thus far, therapies targeting cancer-associated molecular pathways have not given satisfactory results; this is due in part to the rapid upregulation of compensatory alternative pathways as well as dense desmoplastic reaction. In this review, we summarize currently available therapies and clinical trials, directed towards a plethora of pathways and components dysregulated during PDAC carcinogenesis. Emerging trends towards targeted therapies as the most promising approach will also be discussed.

Feasibility of intensity-modulated radiotherapy combined with gemcitabine and S-1 for patients with pancreatic cancer

The aim of the present study was to establish whether intensity-modulated radiotherapy (IMRT) with concurrent gemcitabine and S-1 is a feasible treatment option for patients with locally advanced pancreatic ductal adenocarcinoma. Patients with pancreatic ductal adenocarcinoma were prospectively enrolled. An IMRT dose of 50.4 Gy in 28 fractions with concurrent gemcitabine at a dose of 600 mg/m² and S-1 at a dose of 60 mg were administrated. Adverse events and associated dosimetric factors were assessed. Between February 2012 and January 2014, 17 patients with borderline resectable and 4 with unresectable pancreatic cancer were enrolled. None of the patients experienced grade 3 or worse nausea and vomiting. The planning target volume (≥200 vs. <200 ml) was a statistically significant predictive factor for neutrocytopenia (≥500 vs. 500/µl, P=0.02). Concurrent IMRT with gemcitabine and S-1 for patients with locally advanced pancreatic cancer is feasible, with tolerable hematological toxicities and low gastrointestinal toxicities.

Pancreatectomy with major arterial resection after neoadjuvant chemoradiotherapy gemcitabine and S-1 and concurrent radiotherapy for locally advanced unresectable pancreatic cancer

BACKGROUND

Pancreatic cancer (PC) with arterial invasion is currently a contraindication to resection and has a miserable prognosis.

METHODS

Seventeen patients with locally advanced PC involving the celiac axis and/or common hepatic artery (CHA) who received chemoradiotherapy (CRT) composed of gemcitabine, S-1, and external beam irradiation over the last 2 years were investigated. Thirteen patients underwent pancreatectomy with major arterial resection: 6 distal pancreatectomies with resection of the celiac axis, 4 total pancreatectomies with resection of both the celiac axis and the CHA, and 3 pancreatoduodenectomies with resection of the CHA. Preoperative arterial embolization and/or arterial reconstruction to prevent ischemic gastropathy and hepatopathy was performed in 7 of the 13 patients.

RESULTS

Distant metastases were found in 3 patients after CRT. One patient did not consent to operation after CRT. The morbidity rate of the 13 patients who underwent surgery was 62% (8/13), but no deaths occurred. Although there were no responders on CT, >90% of tumor cells were necrotic on histopathology in 5 of 13 tumors after CRT. Invasion of the celiac axis remained in 5 tumors, and extrapancreatic plexus invasion remained in 8 tumors, but an R0 resection was achieved in 12 of 13 tumors. Lymph node metastases were found in 3 of 13 cases. The overall 1-year survival rate from commencement of CRT and resection was 12 of 13 patients.

CONCLUSION

Neoadjuvant CRT containing gemcitabine and S-1 and subsequent pancreatectomy with major arterial resection for patients with locally advanced PC with arterial invasion were carried out safely with an acceptable R0 resection acceptable morbidity and mortality, and encouraging survival (12 of 13) at 1 year postoperatively.

Predictors of toxicity associated with stereotactic body radiation therapy to the central hepatobiliary tract

PURPOSE

To identify dosimetric predictors of hepatobiliary (HB) toxicity associated with stereotactic body radiation therapy (SBRT) for liver tumors.

METHODS AND MATERIALS

We retrospectively reviewed 96 patients treated with SBRT for primary (53%) or metastatic (47%) liver tumors between March 2006 and November 2013. The central HB tract (cHBT) was defined by a 15-mm expansion of the portal vein from the splenic confluence to the first bifurcation of left and right portal veins. Patients were censored for toxicity upon local progression or additional liver-directed therapy. HB toxicities were graded according to Common Terminology Criteria for Adverse Events version 4.0. To compare different SBRT fractionations, doses were converted to biologically effective doses (BED) by using the standard linear quadratic model α/β = 10 (BED10).

RESULTS

Median follow-up was 12.7 months after SBRT. Median BED10 was 85.5 Gy (range: 37.5-151.2). The median number of fractions was 5 (range: 1-5), with 51 patients (53.1%) receiving 5 fractions and 29 patients (30.2%) receiving 3 fractions. In total, there were 23 (24.0%) grade 2+ and 18 (18.8%) grade 3+ HB toxicities. Nondosimetric factors predictive of grade 3+ HB toxicity included cholangiocarcinoma (CCA) histology (P<.0001), primary liver tumor (P=.0087), and biliary stent (P<.0001). Dosimetric parameters most predictive of grade 3+ HB toxicity were volume receiving above BED10 of 72 Gy (VBED1072) ≥ 21 cm(3) (relative risk [RR]: 11.6, P<.0001), VBED1066 ≥ 24 cm(3) (RR: 10.5, P<.0001), and mean BED10 (DmeanBED10) cHBT ≥14 Gy (RR: 9.2, P<.0001), with VBED1072 and VBED1066 corresponding to V40 and V37.7 for 5 fractions and V33.8 and V32.0 for 3 fractions, respectively. VBED1072 ≥ 21 cm(3), VBED1066 ≥ 24 cm(3), and DmeanBED10 cHBT ≥14 Gy were consistently predictive of grade 3+ toxicity on multivariate analysis.

CONCLUSIONS

VBED1072, VBED1066, and DmeanBED10 to cHBT are associated with HB toxicity. We suggest VBED1072 < 21 cm(3) (5-fraction: V40 < 21 cm(3); 3-fraction: V33.8 < 21 cm(3)), VBED1066 < 24 cm(3) (5-fraction: V37.7 < 24 cm(3); 3-fraction: V32 < 24 cm(3)) as potential dose constraints for the cHBT when clinically indicated.

Treatment of borderline resectable pancreatic cancer

OPINION STATEMENT

Borderline resectable pancreatic adenocarcinoma represents a subset of localized cancers that are at high risk for a margin-positive resection and early treatment failure when resected de novo. Although several different anatomic definitions for this disease stage exist, there is agreement that some degree of reconstructible mesenteric vessel involvement by the tumor is the critical anatomic feature that positions borderline resectable between anatomically resectable and unresectable (locally advanced) tumors in the spectrum of localized disease. Consensus also exists that such cancers should be treated with neoadjuvant chemotherapy and/or chemoradiation before resection; although the optimal algorithm is unknown, systemic chemotherapy followed by chemoradiation is a rational approach. Although gemcitabine-based systemic chemotherapy with either 5-FU or gemcitabine-based chemoradiation regimens has been used to date, newer regimens, including FOLFIRINOX, should be evaluated on protocol. Delivery of neoadjuvant therapy necessitates durable biliary decompression for as many as 6 months in many patients with cancers of the pancreatic head. Patients with no evidence of metastatic disease following neoadjuvant therapy should be brought to the operating room for pancreatectomy, at which time resection of the superior mesenteric/portal vein and/or hepatic artery should be performed when necessary to achieve a margin-negative resection. Following completion of multimodality therapy, patients with borderline resectable pancreatic cancer can expect a duration of survival as favorable as that of patients who initially present with resectable tumors. Coordination among a multidisciplinary team of physicians is necessary to maximize these complex patients' short- and long-term oncologic outcomes.

Current trends in preoperative biliary stenting in patients with pancreatic cancer

BACKGROUND

Sufficient evidence suggests that preoperative biliary stenting is associated with increased complication rates after pancreaticoduodenectomy.

METHODS

Surveillance, Epidemiology, and End Results (SEER) and linked Medicare claims data (1992-2007) were used to identify patients with pancreatic cancer who underwent pancreaticoduodenectomy. We evaluated trends in the use of preoperative biliary stenting, timing of physician visits relative to stenting, and time to surgical resection and symptoms in stented and unstented patients.

RESULTS

Pancreaticoduodenectomy was performed in 2,573 patients, and 52.6% of patients underwent preoperative biliary stenting (N = 1,354). Of these, 75.3% underwent endoscopic stenting only, 18.9% received a percutaneous stent, and 5.8% underwent both procedures. The overall stenting rate increased from 29.6% of patients between 1992 and 1995 to 59.1% between 2004 and 2007 (P < .0001). Preoperative stenting was more common in patients with jaundice, cholangitis, pruritus, or coagulopathy (P < .05 for all). Of stented patients, 77.7% had had a stent placed prior to seeing a surgeon. Stenting prior to surgical consultation was associated with longer indwelling stent time compared to stenting after surgical consultation (37.3 vs 27.0 days, P < .0001). In addition, stented patients had longer times from surgeon visit to pancreatectomy than those who had not received stents (24.2 days vs 17.2 days, P < .0001).

CONCLUSION

Use of preoperative biliary stenting doubled between 1992 and 2007 despite evidence that stenting is associated with increased perioperative infectious complications. The majority of stenting occurred prior to surgical consultation and is associated with significant delay in time to operation. Surgeons should be involved early in order to prevent unnecessary stenting and improve outcomes.

Efficacy of a metallic stent covered with a paclitaxel-incorporated membrane versus a covered metal stent for malignant biliary obstruction: a prospective comparative study

BACKGROUND

The placement of a self-expandable metallic stent (SEMS) is a widely used nonsurgical treatment method in patients with unresectable malignant biliary obstructions but SEMS is susceptible to occlusion by tumor ingrowth or overgrowth.

AIM

The efficacy and safety of a metallic stent covered with a paclitaxel-incorporated membrane (MSCPM) in which paclitaxel provided an antitumoral effect was compared prospectively with those of a covered metal stent (CMS) in patients with malignant biliary obstructions.

METHODS

Patients with unresectable distal malignant biliary obstructions (n = 106) were prospectively enrolled in this study at multiple treatment centers. A MSCPM was inserted endoscopically in 60 patients, and a CMS was inserted in 46 patients. Patients underwent systemic chemotherapy regimens alternatively according to disease characteristics.

RESULTS

The two groups did not differ significantly in mean age, male to female ratio, or mean follow-up period. Stent occlusion due to tumor ingrowth occurred in 12 patients who received MSCPMs and in eight patients who received CMSs. Stent patency and survival time did not differ significantly between the two groups (p = 0.116, 0.981). Chemotherapy had no influence on stent patency, but gemcitabine-based chemotherapy was a significant prognostic factor for survival time (p = 0.012). Complications, including cholangitis and pancreatitis, were found to be acceptable in both groups.

CONCLUSIONS

Although the use of a MSCPM produced no significant differences in stent patency or patient survival in patients with malignant biliary obstructions compared with the use of a CMS, this study demonstrated that MSCPM can be used safely in humans.

Defined clinical classifications are associated with outcome of patients with anatomically resectable pancreatic adenocarcinoma treated with neoadjuvant therapy

BACKGROUND

We previously introduced a classification system for patients with localized pancreatic adenocarcinoma that integrates assessments of tumor anatomy, cancer biology, and patient physiology. By means of this system, we sought to analyze outcomes of patients with resectable anatomy but heterogeneous biology and physiology who were treated with neoadjuvant therapy.

METHODS

We evaluated consecutive patients (2002-2007) with anatomically potentially resectable cancers treated with chemotherapy or chemoradiation before potential pancreatectomy. We compared clinical factors and outcomes of patients classified as having disease that was clinically resectable (CR; no extrapancreatic disease, preserved performance status); suspicion for extrapancreatic disease (BR-B); or marginal performance status or significant comorbidity (BR-C). Patients with borderline resectable anatomy (BR-A) were excluded.

RESULTS

Resection rates for 138 CR, 41 BR-B, and 38 BR-C patients were 75, 46, and 37%, respectively (P < 0.001). Metastases, detected during treatment in 23% of patients, were the most common contraindication to resection among CR (15%) and BR-B (46%) patients. Performance status rarely precluded surgery except among BR-C (32%) patients. Factors associated with selection against surgery were older age, poor performance status, pain, and therapeutic complications (P < 0.05). The median overall survival of all patients was 21 months. Resected and unresected BR-B and BR-C patients had median overall survival durations similar to those of resected and unresected CR patients, respectively (P > 0.22).

CONCLUSIONS

This system describes discrete clinical subgroups of patients with pancreatic cancer who have similar, potentially resectable tumor anatomy but heterogeneous physiology and cancer biology. It may be used with neoadjuvant therapy to predict outcomes, individualize treatment algorithms, and optimize survival.

Adjuvant and neoadjuvant treatment in pancreatic cancer

Pancreatic adenocarcinoma is one of the most aggressive human malignancies, ranking 4th among causes for cancer-related death in the Western world including the United States. Surgical resection offers the only chance of cure, but only 15 to 20 percent of cases are potentially resectable at presentation. Different studies demonstrate and confirm that advanced pancreatic cancer is among the most complex cancers to treat and that these tumors are relatively resistant to chemotherapy and radiotherapy. Currently there is no consensus around the world on what constitutes “standard” adjuvant therapy for pancreatic cancer. This controversy derives from several studies, each fraught with its own limitations. Standards of care also vary somewhat with regard to geography and economy, for instance chemo-radiotherapy followed by chemotherapy or vice versa is considered the optimal therapy in North America while chemotherapy alone is the current standard in Europe. Regardless of the efforts in adjuvant and neoadjuvant improved therapy, the major goal to combat pancreatic cancer is to find diagnostic markers, identifying the disease in a pre-metastatic stage and making a curative treatment accessible to more patients. In this review, authors examined the different therapy options for advanced pancreatic patients in recent years and the future directions in adjuvant and neoadjuvant treatments for these patients.

EUS or percutaneously guided intratumoral TNFerade biologic with 5-fluorouracil and radiotherapy for first-line treatment of locally advanced pancreatic cancer: a phase I/II study

BACKGROUND

TNFeradeBiologic (AdGVEGR.TNF.11D) is a replication-deficient adenoviral vector that expresses tumor necrosis factor-α (TNF-α) under the control of the Egr-1 promoter, which is inducible by chemotherapy and radiation.

OBJECTIVE

This study was conducted to determine the maximal tolerated dose of TNFeradeBiologic with standard chemoradiotherapy and preliminary activity and safety of the combination in the treatment of locally advanced pancreatic cancer (LAPC).

DESIGN

TNFeradeBiologic was injected into locally advanced pancreatic carcinomas by using EUS or percutaneous administration once a week for 5 weeks together with 50.4 Gy radiation and 5-fluorouracil (5-FU) 200 mg/m(2) daily over 5.5 weeks. Dose levels from 4 × 10(9) to 1 × 10(12) particle units (PU) were studied.

SETTING

Multicentered, academic institutions.

PATIENTS

Fifty patients with LAPC were treated.

INTERVENTIONS

Doses of TNFerade Biologic were administered to patients.

MAIN OUTCOME MEASUREMENTS

Toleration of TNFerade Biologic was measured through toxicity and tumor response, by using the criteria of the Response Evaluation Criteria in Solid Tumors and the World Health Organization, and was reviewed by a central radiology facility. Overall survival and progression-free survival were also measured.

RESULTS

Dose-limiting toxicities of pancreatitis and cholangitis were observed in 3 patients at the 1 × 10(12) PU dose, making 4 × 10(11) PU the maximum tolerated dose. One complete response, 3 partial responses, and 12 patients with stable disease were noted. Seven patients eventually went to surgery, 6 had clear margins, and 3 survived >24 months.

LIMITATIONS

This is a Phase 1/2 non-randomized study.

CONCLUSIONS

Intratumoral delivery of TNFerade Biologic by EUS with fine-needle viral injection or percutaneously, combined with chemoradiation, shows promise in the treatment of LAPC. There appeared to be better clinical outcome at the maximal tolerated dose than at lower doses. The dose of 4 ×10(11) PU TNFerade Biologic was generally well tolerated, with encouraging indications of activity, and will be tested in the randomized phase of this study. Delivery of TNFerade Biologic did not interfere with subsequent surgical resection.

Preoperative biliary stents in pancreatic cancer

BACKGROUND

Pancreatic cancer is a common digestive cancer with high mortality, and surgical resection is the only potential curative treatment option. Pancreatic head cancer is usually accompanied by biliary obstruction, which potentially increases surgical complications following pancreaticoduodenectomy. Thus, preoperative biliary drainage has long been advocated.

METHODS

A review of the literature using Medline, Embase and Cochrane databases was undertaken.

RESULTS

Endoscopic or percutaneous biliary stent placement is technically successful in most patients. The use of routine preoperative biliary drainage in the setting of pancreatic cancer with biliary obstruction is controversial. Prospective studies have shown that complications related to preoperative biliary drainage using endoscopic placement of traditional plastic endoprostheses increase the overall morbidity compared to pancreaticoduodenectomy alone. Placement of self-expandable metal stents could reduce stent-related complication rates such as early occlusion because of prolonged patency, especially when surgery is delayed.

CONCLUSION

Pancreatic cancer patients with deep jaundice and expected delay prior to curative intent surgery are potential candidates for temporary biliary drainage. Cholangitis remains a formal indication for early, urgent preoperative biliary decompression for patients with pancreatic cancer.

Paclitaxel-eluting covered metal stents versus covered metal stents for distal malignant biliary obstruction: a prospective comparative pilot study

BACKGROUND

In unresectable malignant biliary obstruction, stent insertion can be the treatment of choice. However, metal stents are susceptible to occlusion by tumor ingrowth or overgrowth. The recently introduced paclitaxel-eluting covered metal stents (PECMSs) may prevent occlusion from tumor ingrowth by the antitumor effect of paclitaxel.

OBJECTIVE

Our goal was to compare the efficacy and complication rates of PECMSs and the control covered metal stents (CCMSs) in patients with malignant biliary obstruction.

DESIGN

Prospective, randomized pilot study.

SETTING

Single tertiary referral center.

PATIENTS

From November 2006 to June 2008, 52 patients with unresectable distal malignant biliary obstruction were enrolled. A PECMS was inserted in 26 patients and a CCMS in 26 patients. Of these patients, 2 patients in the PECMS group and 1 patient in the CCMS group were excluded. Finally 49 patients (24 patients in the PECMS group and 25 patients in the CCMS group) were included in the analysis.

INTERVENTIONS

PECMSs and CCMSs were inserted by using the standard ERCP technique.

RESULTS

The mean follow-up period was 194.0 ± 144.2 days in the PECMS group and 238.8 ± 147.4 days in the CCMS group (P = .287). The stent patency duration and survival time were not significantly different between the 2 groups (P = .307 and P = .596, respectively). Stent occlusion caused by tumor ingrowth occurred in 5 patients in the PECMS group. In the CCMS group, stent occlusion caused by tumor ingrowth (n = 4) or distal stent migration (n = 4) occurred in 8 patients. In the PECMS group, 3 cases of transient cholangitis-like symptoms without stent occlusion and 1 case of pancreatitis occurred after stent insertion. One patient in the CCMS group experienced pancreatitis.

LIMITATIONS

This study was a pilot study in which no power calculation was done. It was performed at a single center and was performed in a nonblinded fashion.

CONCLUSIONS

PECMSs may be safe with acceptable complication rates. There were no significant differences in the duration of stent patency and patient survival time between PECMSs and CCMSs in patients with distal malignant biliary obstruction. However, a larger study powered to detect differences must be done to conclude that there is any benefit of PECMSs.

Bridge to surgery using partially covered self-expandable metal stents (PCMS) in malignant biliary stricture: an acceptable paradigm?

BACKGROUND AND AIM

Partially covered self-expanding metal stents (PCMS) have been extensively used for palliation of malignant distal biliary stricture. Many centers have been using them as a bridge to surgery (BTS) regardless of resectability with or without eventual neoadjuvant therapy. We analyzed the outcome of all patients receiving PCMS and subsequently referred for surgery in our institution.

METHODS

Our prospectively established pancreaticobiliary database was retrospectively analyzed to retrieve all patients with malignant biliary stricture who underwent PCMS placement and subsequently went for curative surgical attempt at our institution. Cancer type and staging, adverse events related to stent placement or surgery, type of surgery performed, time between stenting and surgery, length of postoperative hospitalization, and postoperative follow-up were recorded.

RESULTS

27 patients (21 men; median age 66 years, range 39-82 years) received PCMS. Indications for placement included biliary stricture related to pancreatic cancer (n=23) or other malignancies (n=4). Median time between stenting and surgery was 32 days (range 6-569 days). Median time of hospitalization post surgery was 7 days (1-40 days). All patients underwent exploratory laparoscopy, followed in 9 (33.3%) by Whipple procedure with uneventful removal of the PCMS. Eighteen patients (66.6%) had their attempted curative resection terminated early due to intraoperative evidence of metastatic spread, with 8 (30%) patients undergoing peritoneal or liver metastasis biopsy. PCMS were left in place in those 18 patients. Complications related to PCMS in the bridge-to-surgery period included migration (n=2, 7.4%) and tissue overgrowth (n=1, 3.4%), all of them managed by endoscopic removal and replacement with PCMS. Median follow-up post surgery was 210 days (range 9-1,642 days).

CONCLUSION

PCMS are an appropriate BTS option. For resectable patients, PCMS results in biliary drainage and allows for neoadjuvant treatment without portending subsequent curative resection (Whipple). For unresectable patients, long-term biliary drainage is provided by PCMS.

Prior Biliary Tree Instrumentation Does Not Preclude Hepatic Arterial Therapy for Malignancy

Hepatic arterial therapy (HAT) has become an accepted alternative for patients with unresectable hepatic malignancies. HAT has an acceptable toxicity profile, yet its safety for use in patients who have undergone significant biliary manipulation is undocumented. A retrospective review identified 18 consecutive patients with unresectable hepatic malignancies who had undergone significant prior biliary tree manipulation. All patients received peri-HAT antibiotics. Clinicopathologic, treatment-related, and outcomes data were collected and analyzed. Eighteen patients who had HAT were analyzed; 72 per cent were men, the median age was 61 years, and 61 per cent had greater than 25 per cent hepatic parenchymal replacement by tumor. Seventy-eight per cent of patients had an indwelling biliary stent and 22 per cent had undergone a hepaticojejunostomy Twenty-two per cent of patients developed a complication, none of which were infectious, and there were no peri-HAT deaths. The majority of patients had evidence of either a partial response (55%) or stable disease (22%) upon follow-up. One patient had a complete response to HAT. The median survival was 27 months. Hepatic arterial therapy seems to be safe for patients with unresectable hepatic malignancies and a history of significant biliary instrumentation. There is no increased risk of infectious complications in this population after HAT

[Bleeding from gastric varices as the initial manifestation of primary pancreatic lymphoma]

In patients with pancreatic cancer, the most frequent symptoms are abdominal pain, weight loss and jaundice. Upper gastrointestinal bleeding produced by gastric varices is a rare entity in these patients and requires the presence of splenic vein thrombosis (SVT) to be excluded. We describe the case of a young man who presented to the emergency department with hematemesis. Diagnostic tests revealed primary pancreatic lymphoma (PPL), which provoked splenic vein thrombosis, collateral circulation and the formation of isolated bleeding gastric varices. To date, we have found no reports in the literature of PPL with this form of presentation. Finally, we review the literature, with emphasis on the importance of excluding splenic vein thrombosis in patients with isolated gastric varices, and discuss certain features of the diagnosis and treatment of PPL.

Preoperative biliary drainage in malignant obstruction: indications, techniques, and the debate over risk

In patients with malignant biliary obstruction considered suitable for surgical resection, preoperative drainage might be expected to improve surgical outcomes by restoring liver function and improving nutritional status. In practice, however, the benefits of preoperative drainage are far from clear. Studies to date have reported differing outcomes, and some have suggested that morbidity and mortality are greater in patients undergoing drainage than in those proceeding directly to surgery. The development of clinical guidelines has been limited by the lack of convincing randomized data, which in turn has led to variations in practice. This article examines the arguments for and against preoperative biliary drainage, the conflicting data on the subject, and the techniques used.

Phase I trial of the human immunodeficiency virus protease inhibitor nelfinavir and chemoradiation for locally advanced pancreatic cancer

PURPOSE

Preclinically, HIV protease inhibitors radiosensitize tumors with activated PI3-kinase/Akt pathway. We determined the toxicity of nelfinavir chemoradiotherapy in borderline resectable and unresectable pancreatic cancer.

PATIENTS AND METHODS

Oral nelfinavir (2 x 1,250 mg) was started 3 days before and continued throughout chemoradiotherapy to 50.4 Gy (boost, 59.4 Gy) in 12 patients. Two gemcitabine dose levels (DL) were tested (200 mg/m(2) and 300 mg/m(2) on days 1, 8, 22, and 29). Cisplatin was administered on the same days at 30 mg/m(2). Phospho-Akt downregulation by nelfinavir was monitored by immunoblotting in patient leukocytes. Restaging positron emission tomography (PET)/computed tomography (CT) and CA19-9 levels served to assess response, and responding tumors were resected.

RESULTS

At each DL, five of six patients completed chemoradiotherapy, and two of 12 patients had incomplete chemoradiotherapy because of clinical depression (DL1) and peritoneal metastasis (DL2). Grade 4 toxicities were a transaminase elevation (DL2) as a result of biliary stent occlusion and acute cholecystitis as a result of peritoneal metastasis (DL2). Stent occlusions led to dose-limiting toxicities of grade 3 liver enzyme and bilirubin elevations (two patients at DL1, one patient at DL2). Grade 3 nausea and vomiting occurred in a DL2 patient, and weight loss occurred in a DL1 patient who refused supportive feeding. Secondary complete resection was possible in six of 10 patients with complete chemoradiotherapy, including one tumor with pathologic sterilization. Partial CT responses were observed in five of 10 patients who completed chemoradiotherapy. Of nine patients assessable by PET,responses were complete in five patients and partial patients, and stable disease was observed in two patients.

CONCLUSION

The combination of nelfinavir and chemoradiotherapy showed acceptable toxicity and promising activity in patients with pancreatic cancer.

Human application of a metallic stent covered with a paclitaxel-incorporated membrane for malignant biliary obstruction: multicenter pilot study

BACKGROUND

Paclitaxel, with its antitumor effect, may improve the function of metallic stents used for biliary drainage. However, clinical studies that use metallic stents covered with a paclitaxel-incorporated membrane (MSCPM) in the biliary tract of human beings have not been previously carried out.

OBJECTIVE

To evaluate the safety and efficacy of an MSCPM for patients with malignant biliary obstruction.

DESIGN AND SETTING

A case series that includes 4 endoscopy centers.

PATIENTS

From July 2003 to August 2006, a total of 21 patients diagnosed with unresectable malignant biliary obstruction.

INTERVENTION

Endoscopic placement of an MSCPM.

MAIN OUTCOME MEASUREMENTS

Stent occlusion, complications, stent patency, patient survival, and the periodic mean concentration of paclitaxel in the blood.

RESULTS

Occlusion of the MSCPM was observed in 9 patients and was caused by bile sludge or clog in 4, tumor overgrowth in 3, and tumor ingrowth in 2. Complications included obstructive jaundice in 6, cholangitis in 3, and 1 patient showed stent migration with cholecystitis. The mean patency of a MSCPM was 429 days (median 270 days, range 68-810 days) and cumulative patency rates at 3, 6, and 12 months were 100%, 71%, and 36%, respectively. The mean survival of patients was 350 days (median 281 days, range 68-811 days). The highest concentration of paclitaxel in the blood was found between 1 and 10 days after insertion.

LIMITATIONS

Small number of patients and low rate of pathologic diagnosis.

CONCLUSIONS

The endoscopic insertion of MSCPM is technically feasible, safe, and effective in patients with malignant biliary obstruction. In addition, MSCPM may exert local antitumor activity because of the steady release of paclitaxel.

Future chemoradiation strategies in pancreatic cancer

Although not universally accepted, 5-fluorouracil (5-FU)-based chemoradiation is considered a standard treatment for patients with localized pancreatic cancer. Randomized trials have indicated that chemoradiation improves median survival of both locally advanced and resected pancreatic cancer. While the use of adjuvant chemoradiation in pancreatic cancer has been called into question since the publication of the European Study Group for Pancreatic Cancer (ESPAC)-1 trial, this study has not changed standard practice in the United States. All randomized trials investigating adjuvant chemoradiation have reported significant local as well as distant disease control limitations, making the study of novel chemoradiation and adjuvant chemotherapy important. Selected centers are investigating neoadjuvant chemoradiation in radiographically resectable patients. Advantages of neoadjuvant chemoradiation compared to postoperative therapy include increased local control, increased access to therapy, addressing the systemic disease recurrence risk without delay, and optimal patient selection for pancreaticoduodenectomy through exclusion of patients with rapidly progressive metastatic disease. In the years since it was approved for use in pancreatic cancer, gemcitabine has stood the test of time as a systemic agent but has not been widely adopted as a radiosensitzer in pancreatic cancer. Single-arm clinical trials that initially explored gemcitabine as a radiosensitzer in locally advanced pancreatic cancer demonstrated the potential for significant toxicity without dramatic improvements in efficacy. Recent strategies for improving the efficacy of chemoradiation include improved chemoradiation sensitization through the concurrent incorporation of molecular targeted agents, and the use of new radiation technology such as intensity-modulated radiotherapy (IMRT) and stereotactic radiotherapy. Herein, we discuss the relative merits of strategies that seek to improve outcome through these novel means and present recent data from novel strategies that will provide the background for future trials.

Impact of preoperative chemoradiotherapy on survival in patients with resectable pancreatic cancer

AIM: To explore whether preoperative chemoradiation therapy improves survival of patients with pancreatic cancer undergoing resectional surgery.

METHODS: Forty-seven patients with a malignant pancreatic tumor localized in the head or uncinate process of the pancreas underwent radical pancreatico-duodenectomy. Twenty-two received chemoradiation therapy (gemcitabine and radiation dose 50.4 Gy) before surgery (CRR) and 25 patients underwent surgery only (RO). The study was non-randomised. Patients were identified from a prospective database.

RESULTS: The median survival time was 30.2 mo in the CRR group and 35.9 mo in the RO group. No statistically significant differences were found in subclasses according to lymph node involvement, TNM stages, tumor size, or perineural invasion. The one, three and five year survival rates were 81%, 33% and 33%, respectively, in the CRR group and 72%, 47% and 23%, respectively, in the RO group. In ductal adenocarcinoma, the median survival time was 27 mo in the CRR group and 20 mo in the RO group. No statistically significant differences were found in the above subclasses. The one, three and five year survival rates were 79%, 21% and 21%, respectively, in the CRR group and 64%, 50% and 14%, respectively, in the RO group. The overall hospital mortality rate was 2%. The morbidity rate was 45% in the CRR group and 32% (NS) in the RO group.

CONCLUSION: Major multicenter randomized studies are needed to conclusively assess the impact of neoadjuvant treatment in the management of pancreatic cancer.

A randomized phase 2 trial of neoadjuvant chemotherapy in resectable pancreatic cancer: gemcitabine alone versus gemcitabine combined with cisplatin

BACKGROUND

Survival after surgery for pancreas cancer remains low. This improves with adjuvant chemotherapy, but up to 30% patients do not receive the prescribed treatment. Neoadjuvant therapy may increase the proportion of patients who receive all treatment components, may downstage disease before surgery, and may provide early treatment of micrometastases. This randomized phase 2 study compares gemcitabine-based chemotherapy regimens to identify the most promising regimen for future study.

METHODS

Fifty patients with potentially resectable pancreas lesions were enrolled onto the study. Twenty-four patients were randomized to gemcitabine (1000 mg/m(2)) every 7 days for 43 days; 26 patients were randomized to gemcitabine (1000 mg/m(2)) and cisplatin (25 mg/m(2)), 7 to the original schedule (omitting day 22) and 19 to a revised schedule due to neutropenia (omitting days 15 and 36). The primary outcome measure was resection rate.

RESULTS

Patients who were allocated to gemcitabine received a median of 85% of the planned dose. Patients who were allocated to combination treatment received a median of 88% and 92% of the planned gemcitabine and cisplatin doses, respectively. There were 10 episodes of grade III/IV hematological toxicity in each group. Twenty-seven patients (54%) underwent pancreatic resection, 9 (38%) in the gemcitabine arm and 18 (70%) in the combination arm, with no increase in surgical complications. To date, 34 patients (68%) have died. Twelve-month survival for the gemcitabine and combination groups was 42% and 62%.

CONCLUSIONS

Chemotherapy can be safely administered before pancreatic surgery. Combination therapy with gemcitabine and cisplatin is associated with a high resection rate and an encouraging survival rate, suggesting that further study is warranted.

The current standard of care in the periprocedural management of the patient with obstructive jaundice

This review provides a literature-based guide to the optimal management of the patient with obstructive jaundice with emphasis placed on prevention of complications.

[The role of neoadjuvant chemoradiation in pancreatic cancer]

Although complete surgical resection, when possible, leads to prolonged survival in pancreatic cancer, if used alone, its results remain sub-optimal. Neoadjuvant strategies are recent in pancreatic cancer: in primary resectable tumors, they ensure that all patients obtain additional treatment to complete surgery; in locally advanced tumors, they allow a better selection of candidates for curative resection. By delaying surgery, neoadjuvant strategies modify the initial diagnostic process and the symptomatic treatment of pancreatic cancer. Several recent phase I-II studies have confirmed the feasibility and efficacy of the association of chemotherapy and radiotherapy, which is well-tolerated and is associated with better local control and survival. Due to the aggressiveness of pancreatic cancers, most recent cytotoxic agents should be associated with modern radiation techniques. Neoadjuvant chemoradiation is under evaluation in pancreatic cancers, and no randomized phase III trials comparing neoadjuvant and adjuvant therapeutic sequences has been reported. Moreover, radiological and pathological evaluations, not only at diagnosis, but also after preoperative chemoradiation, must be standardized to improve the selection of patients who will benefit from this multi-modal treatment.

Borderline resectable pancreatic cancer: definitions, management, and role of preoperative therapy

With recent advances in pancreatic imaging and surgical techniques, a distinct subset of pancreatic tumors is emerging that blurs the distinction between resectable and locally advanced disease: tumors of "borderline resectability." In our practice, patients with borderline-resectable pancreatic cancer include those whose tumors exhibit encasement of a short segment of the hepatic artery, without evidence of tumor extension to the celiac axis, that is amenable to resection and reconstruction; tumor abutment of the superior mesenteric artery involving <180 degrees of the circumference of the artery; or short-segment occlusion of the superior mesenteric vein, portal vein, or their confluence with a suitable option available for vascular reconstruction because the veins are normal above and below the area of tumor involvement. With currently available surgical techniques, patients with borderline-resectable pancreatic head cancer are at high risk for a margin-positive resection. Therefore, our approach to these patients is to use preoperative systemic therapy and local-regional chemoradiation to maximize the potential for an R0 resection and to avoid R2 resections. In our experience, patients with favorable responses to preoperative therapy (radiographical evidence of tumor regression and improvement in serum tumor marker levels) are the subset of patients who have the best chance for an R0 resection and a favorable long-term outcome.

Primary pancreatic lymphoma--pancreatic tumours that are potentially curable without resection, a retrospective review of four cases

Background

Primary pancreatic lymphomas (PPL) are rare tumours of the pancreas. Symptoms, imaging and tumour markers can mimic pancreatic adenocarcinoma, but they are much more amenable to treatment. Treatment for PPL remains controversial, particularly the role of surgical resection.

Methods

Four cases of primary pancreatic lymphoma were identified at Prince of Wales Hospital, Sydney, Australia. A literature review of cases of PPL reported between 1985 and 2005 was conducted, and outcomes were contrasted.

Results

All four patients presented with upper abdominal symptoms associated with weight loss. One case was diagnosed without surgery. No patients underwent pancreatectomy. All patients were treated with chemotherapy and radiotherapy, and two of four patients received rituximab. One patient died at 32 months. Three patients are disease free at 15, 25 and 64 months, one after successful retreatment. Literature review identified a further 103 patients in 11 case series. Outcomes in our series and other series of chemotherapy and radiotherapy compared favourably to surgical series.

Conclusion

Biopsy of all pancreatic masses is essential, to exclude potentially curable conditions such as PPL, and can be performed without laparotomy. Combined multimodality treatment, utilising chemotherapy and radiotherapy, without surgical resection is advocated but a cooperative prospective study would lead to further improvement in treatment outcomes.

Delayed pancreaticoduodenectomy for cancer patients with prior ERCP-placed, nonforeshortening, self-expanding metal stents: a positive outcome

BACKGROUND

Self-expanding metal stents (SEMS) inserted for malignant biliary obstruction are felt to be contraindicated in patients with resectable disease. Anecdotally, we observed a number of "unresectable" patients eventually undergoing a "delayed" pancreaticoduodenectomy after additional surgical opinions. This has not been previously described in the literature.

OBJECTIVE

To quantitate the frequency with which patients diagnosed with unresectable pancreaticobiliary malignancy (and hence undergoing SEMS placement) eventually undergo Whipple's resection, and to report on the outcomes in these patients.

DESIGN AND SETTING

This retrospective, observational study was conducted at a single tertiary care medical center.

PATIENTS AND INTERVENTIONS

One hundred consecutive patients who underwent non-foreshortening SEMS placement for presumed unresectable pancreaticobiliary malignancy were identified from our ERCP database. The clinical course and any subsequent operative interventions were reviewed.

RESULTS

Despite apparent unresectability, 13 of 100 patients underwent delayed surgical exploration for an attempt at resection. Whipple's resection was successfully performed in 5 patients. No interference with the biliary anastomosis was noted. No unresectable patient required surgical biliary bypass because of the presence of the stent. No pre- or postoperative infections occurred.

CONCLUSIONS

Non-foreshortening metal stents can be precisely positioned below the line of any potential surgical transection. The lower risk of preoperative metal stent occlusion, compared to plastic stents, minimizes the risk of postoperative infection. At surgery, unresectable patients do not require unnecessary biliary bypass if a properly positioned SEMS is in place. Properly placed non-foreshortening biliary metal stents are not a contraindication to delayed attempts at Whipple's resection and may be beneficial.

The argument for pre-operative chemoradiation for localized, radiographically resectable pancreatic cancer

Although not universally accepted, chemoradiation is considered a standard adjuvant treatment for patients with resected pancreatic cancer. Theoretical advantages of reduced toxicity and increased efficacy with the use of pre-operative chemoradiation compared to post-operative adjuvant chemoradiation have recently been validated with the publication of a phase III trial in the adjuvant treatment of rectal cancer. Additional advantages of pre-operative chemoradiation that apply specifically to pancreatic cancer include increased access to therapy in patients treated before surgery, addressing the systemic disease recurrence risk without delay, and optimal patient selection for pancreaticoduodenectomy through exclusion of patients with rapidly progressive metastatic disease. Critical components of a pre-operative treatment strategy for pancreatic cancer include adherence to a strict definition of resectability, accurate radiographic staging capable of identifying patients with potentially resectable disease, and a safe and efficient means of obtaining a tissue diagnosis and relieving biliary obstruction. Herein, we discuss the rationale for the use of pre-operative chemoradiation in pancreatic cancer, the results of treatment, and future strategies to address the pattern of disease recurrence.

Staging of pancreatic cancer with multidetector CT in the setting of preoperative chemoradiation therapy

BACKGROUND

Preoperative chemoradiation can potentially improve outcomes in patients with pancreatic cancer. This study addresses its effect on staging pancreatic cancer with multidetector computed tomography (MDCT).

METHODS

Fifty-five patients underwent a dual-phase MDCT pancreas protocol for proved pancreatic cancer. Of these, 16 patients underwent preoperative chemoradiation. Three radiologists independently reviewed images to assess for locally advanced disease, liver and peritoneal metastases on baseline studies of all 55 patients, and on follow-up preoperative studies for the 16 patients receiving preoperative therapy. Overall score for resectability was graded on a scale from 1 to 5 (1, definitely resectable; 5. definitely unresectable). Receiver operating characteristic curves and weighted (kappa statistics were determined.

RESULTS

The areas under the receiver operating characteristic curves for readers 1, 2, and 3 were 0.98, 0.96, and 0.90, respectively. Weighted kappa values for reader 1 versus reader 2, reader 1 versus reader 3, and reader 2 versus reader 3 were 0.90, 0.57, and 0.54, respectively. Interpreting scores of 1 to 3 for resectability as resectable disease, the mean values for sensitivity, specificity, negative predictive value, positive predictive value, and accuracy were 0.92, 0.91, 0.74, 0.98, and 0.92 respectively.

CONCLUSION

The negative predictive value for MDCT for identifying unresectable pancreatic cancer in the setting of preoperative therapy is comparable to that reported in the absence of neoadjuvant therapy.

Long term morbidity of neoadjuvant chemoradiation for pancreatic head adenocarcinoma

PURPOSE

To report the long term risks of neoadjuvant chemoradiation (NCRT) after duodenopancreatectomy (DP) for adenocarcinoma of the head of pancreas.

METHODS

Between January 1996 and December 2002, 26 patients with biopsy-proven adenocarcinoma of the head of pancreas were treated by this combination of therapies.

RESULTS

Two patients had delayed NCRT-related small bowel infarction: one died from superior mesenteric artery stenosis 36 months after DP without recurrence at laparotomy; there was one limited infarction 16 months after DP.

CONCLUSIONS

Long term vascular morbidity after NCRT is significant.

Use of expandable metallic biliary stents in resectable pancreatic cancer

AIM

To compare the efficacy of metal versus plastic stents for biliary strictures in patients with surgically resectable pancreatic cancer.

METHODS

The medical records at MD Anderson Caner Center from September 2001 to May 2004 were reviewed. Fifty-five patients were identified to have either a metal biliary stent (13 patients, group A) or a plastic biliary stent (42 patients, group B) and subsequently went to surgery. These two groups were compared with regards to number of stents placed prior to surgery, time period between the last stent and surgery, and operative and postoperative complications.

RESULTS

Of the 13 patients in group A, 12 had pancreaticoduodenectomy performed and one had exploration only due to the peritoneal metastatses discovered at the time of surgery. Of the 12 patients with pancreaticoduodenectomy, 10 had pancreatic adenocarcinoma, 1 intraductal papillary mucinous tumor, and 1 ampullary cancer. Only 2 patients required an additional endoscopic retrograde cholangiopancreatography (ERCP) after initial metal stent placement until surgery. The average time between last stent placement and surgery was 106.5 days. Of the 42 patients in group B, 35 had pancreaticoduodenectomy and 7 had either palliative surgery or exploration due to metastatic diseases discovered at the time of surgery. Of the 35 patients, 27 had pancreatic adenocarcinoma, 5 ampullary cancer, 1 neuroendocrine tumor, 1 microcystic adenoma, and 1 autoimmune pancreatitis. Sixteen patients (38%) in group B required 3 or more ERCPs with plastic stents prior to surgery. The average time between last stent placement and surgery was 56.4 days. Preoperative chemoradiation was given to all 13 patients in group A and 31 of 42 patients in group B. There were no stent-related intra- or postoperative complications in both groups. Two of 13 patients (15%) with metal stents versus 39 of 42 patients (93%) with plastic stents, however, developed either cholangitis or cholestasis due to stent occlusion while waiting for surgery.

CONCLUSIONS

Contrary to the belief that metal stents are contraindicated for patients with surgically resectable pancreatic cancer, our study demonstrated that metal stents provided a longer patency rate, fewer ERCP sessions, and fewer episodes of cholangitis without adding any intra- or postoperative complications. Therefore, metal stents should be considered for patients with resectable pancreatic cancer, especially if surgery is not immediately planned as more patients are now receiving preoperative chemoradiation.

Preoperative locoregional re-evaluation by endoscopic ultrasound in pancreatic ductal adenocarcinoma after neoadjuvant chemoradiation

INTRODUCTION

The accuracy of endoscopic ultrasound (EUS) for the diagnosis and staging of pancreatic ductal adenocarcinoma (PDA) has been confirmed. Chemo-radiotherpay (CRT) induces tumor changes which can limit the accuracy of EUS. The aim of our study was to analyze the efficacy of EUS following neoadjuvant CRT comparing findings with the pathology results.

PATIENTS AND METHODS

From November 1996 to October 2003, 45 patients with histologically proven and EUS-staged PDA were treated with neo-adjuvant CRT and radical surgery. All were restaged before surgery using both EUS and computed tomography. Fifteen patients were found to have developed distant metastases. Thirty patients finally underwent pancreaticoduodenectomy (N=24) or distal pancreatectomy (N=6).

RESULTS

Following CRT, tumor stage was correctly assessed in 12 patients (40%). The most frequent misinterpretation was overestimation of tumor size (N=13, 43.3%). Locoregional vascular invasion of veins was suspected by EUS in 13 patients (43.3%) but surgical findings and the histological examination were both negative. Node status was correctly assessed in 27 patients (90%) but nodal involvement was found on the histological specimen in only 3 patients.

CONCLUSION

Preoperative EUS after neoadjuvant CRT for PDA does not enable reliable definitive selection of patients for surgery, probably due to radiation-induced pancreatic changes.

Modern management of pancreatic carcinoma

Pancreatic cancer remains a fearsome disease. New insights into the molecular pathogenesis may influence choice of treatment modalities and provide avenues for novel therapeutic strategies for testing in the clinic. The survival rate of patients with all stages of disease is poor and clinical trials are appropriate alternatives for treatment and should be considered. Surgical resection, when possible, remains the primary treatment modality and can result in long-term cure. Less invasive techniques such as laparoscopy may reduce the rate of unnecessary laparotomies. The role of adjuvant therapy is re-emerging. Patients with unresectable and metastatic disease are incurable and optimal palliation is the goal. These patients may benefit from palliative bypass of biliary or duodenal obstruction if symptomatic. Pain associated with local tumour infiltration may be palliated with radiation, with or without chemotherapy, or with coeliac nerve blocks or local neurosurgical procedures. Chemotherapy with gemcitabine has modest objective response rates but has been shown to improve symptoms.

Adjuvant therapy for pancreatic cancer: an evolving paradigm

Pancreatic cancer is the fourth leading cause of death in men and fifth in women in the United States. The median survival is 8 to 12 months for patients with locally advanced and unresectable disease and only 3 to 6 months for those with metastatic disease at presentation. Surgical resection offers the only potentially curative treatment. However, only 15% to 20% of patients present with tumors amenable to resection at initial diagnosis. Even for those who undergo resection, the prognosis remains poor. The 5-year survival following pancreaticoduodenectomy is only about 25% to 30% for node-negative tumors and 10% for node-positive tumors. Because of the dismal outcome for patients with resectable pancreatic cancer, adjuvant therapy has been administered in an attempt to improve the local control and overall survival. This review highlights historic and current perspectives of adjuvant therapy in resected pancreatic cancer.

Neoadjuvant chemoradiation with tegafur in cancer of the pancreas: initial analysis of clinical tolerance and outcome

The early institutional experience in the neoadjuvant treatment of potentially resectable pancreatic carcinoma using oral Tegafur as radioenhancing agent is analyzed. Fifteen patients (10 male and 5 female, mean age of 61 years) were treated over a 30-month period. Tegafur dose was 1,200 mg/d along the external radiotherapy period (45-55 consecutive days). Preoperative radiotherapy achieved a total dose of 45 to 50 Gy (1.8 Gy/d). Intraoperative electron boost (10-15 Gy) was delivered at the time of surgery. Hematologic tolerance showed a significant decrease of neutrophil and platelet counts from the outset to the end of the neoadjuvant period (p = 0.001 and p = 0.004, respectively). Five grade III vomiting episodes (33%) were also registered. In 9 patients (60%), surgical resection was performed after chemoradiation. Three complete pathologic responses (pT0 specimens) were identified; in seven cases, the resection achieved tumor-free surgical margins of the specimen. With a median follow-up of 21 months, median survival time was 17 months, with actuarial rates of 45% at 1 year and 24% at 3 years. Median survival for the resected patients was 23 months, and for the unresected patients median survival was 8 months (p = 0.02). The overall median survival in completely resected patients was 28 months, with a 71% survival rate at 1 and 3 years. It is concluded that the treatment scheme described is feasible and acceptably tolerated. The use of oral Tegafur seems to induce results similar to those of other therapeutic protocols using intravenous radioenhancing chemotherapy.

Combined 90Yttrium-DOTA-labeled PAM4 antibody radioimmunotherapy and gemcitabine radiosensitization for the treatment of a human pancreatic cancer xenograft

We have examined the application of (90)Y-DOTA-cPAM4, anti-MUC1 IgG, in combination with the front-line drug gemcitabine as a potential therapeutic for pancreatic cancer. Athymic nude mice bearing CaPan1 human pancreatic cancer xenografts were administered 2 mg of gemcitabine on days 0, 3, 6, 9 and 12 with concurrent (90)Y-DOTA-cPAM4 (100 microCi) provided on day 0. A second group of mice received a second cycle of treatment 5 weeks after the start of the first cycle. Control groups of mice included those that received either treatment arm alone, the combined modality treatment employing a nontargeting control antibody (hLL2, anti-B-cell lymphoma) and a final group that was left untreated. Gemcitabine administered as a single agent provided no antitumor effect. A single cycle of the combined (90)Y-DOTA-cPAM4 and gemcitabine treatment provided greater inhibition of tumor growth than was observed for any of the other treatment procedures. Tumor growth was delayed for a period of 7 weeks. Two cycles of gemcitabine with concomitant (90)Y-DOTA-cPAM4 yielded significant tumor regression and increased median survival to 21 weeks vs. 12 weeks for mice receiving a single cycle of therapy (p<0.024). Median tumor volume doubling-times were 18 weeks in mice treated with 2-cycles of therapy vs. 7 weeks in mice given only 1-cycle (p<0.001), and 3.5 weeks for the group that received 2-cycles of gemcitabine concomitant with equitoxic nontargeting (90)Y-DOTA-hLL2 (p<0.001). These data suggest that addition of (90)Y-DOTA-cPAM4 RAIT to a gemcitabine treatment regimen may provide enhanced antitumor efficacy for the treatment of pancreatic cancer.

Biliary and pancreatic stents

The use of biliary and pancreatic stents has increased significantly during the last 2 decades because of improvements in available endoscopes and endoscopic accessories, as well as better techniques. The number of endoscopists who can successfully complete these demanding procedures has also increased, as have the indications for stent therapy in biliary and pancreatic diseases. Stents are now made in various shapes and configurations from different types of polymers (plastics), various expandable metallic alloys, and bioabsorbable materials. Most of the available data relate to plastic and metallic stents for biliary tract disease; the data for pancreatic disease are fewer and involve a smaller number of patients. This article reviews the most recent available data concerning biliary and pancreatic stents and discusses possible future developments. It does not attempt to cover all data reported in biliopancreatic stent therapy.

Neoadjuvant preoperative chemoradiation in patients with pancreatic cancer

PURPOSE

To assess the toxicity and efficacy of preoperative chemoradiation in pancreatic cancer.

METHODS AND MATERIALS

Between November 1996 and December 2001, 32 patients with biopsy-proven pancreatic adenocarcinoma (28 head; 4 body) were treated by chemoradiation consisting of either split-course therapy (two courses of 15 Gy separated by a 2-week break, n = 10) or standard-fractionation therapy (45 Gy during 5 weeks, n = 22). Concurrent chemotherapy included continuous infusion of 5-fluorouracil and a cisplatin bolus. Pancreatic resection was scheduled for 4-6 weeks after completion of chemoradiation treatment.

RESULTS

All 32 patients completed the chemoradiation protocol. Only 2 cases of Grade 3 toxicity (weight loss, vomiting) and one fatal Grade 4 infection occurred. Of the 32 patients, 19 underwent curative resection. Two patients had a complete pathologic response. One patient died 36 months after diagnosis of late treatment-related toxicity (acute superior mesenteric artery thrombosis) with no evidence of disease. The 2-year overall survival rate for the entire group and the resected patients was 37.3% (95% confidence interval 18.2-56.4%) and 59.3% (95% confidence interval 34.1-84.9%), respectively.

CONCLUSION

Preoperative chemoradiation with 5-fluorouracil and cisplatin is feasible and promising.

Palliative and postoperative radiotherapy in biliary tract cancer

Local failure is the primary limitation for cure in patients with BTC. whether or not they have been resected. The use of radiotherapy with or without chemotherapy in the postoperative setting is controversial, but some studies have reported improvement in 5-year survival. In patients with unresectable BTC, EBRT offers effective palliation of symptomatic disease and has resulted in improved median and long-term survival in a small number of patients in most studies. Novel approaches, including neoadjuvant chemoradiotherapy combined with OLT, and escalated conformal irradiation, seem to be promising and warrant further investigation.

Localized adenocarcinoma of the pancreas: the rationale for preoperative chemoradiation

Pancreatic adenocarcinoma is the fifth leading cause of cancer-related death in the U.S. In spite of advancements in surgical treatment, nearly 80% of patients thought to have localized pancreatic cancer die of recurrent or metastatic disease when treated with surgery alone. Therefore, efforts to alter the patterns of recurrence and improve survival for patients with pancreatic cancer currently focus on the delivery of systemic therapy and irradiation before or after surgery. Postoperative adjuvant therapy appears to improve median survival. However, more than one-fourth of patients do not complete planned adjuvant therapy due to surgical complications or a delay in postoperative recovery of performance status. Utilizing a preoperative (neoadjuvant) approach, overall treatment time is reduced, a greater proportion of patients receive all components of therapy, and patients with rapidly progressive disease are spared the side effects of surgery as metastatic disease may be found at restaging following chemoradiation (prior to surgery). This paper examines the factors pertinent to clinical trial design for resectable pancreatic cancer, and carefully reviews the existing data supporting adjuvant and neoadjuvant therapy for potentially resectable disease.

Effect of preoperative biliary decompression on pancreaticoduodenectomy-associated morbidity in 300 consecutive patients

OBJECTIVE

To examine the relationship between preoperative biliary drainage and the morbidity and mortality associated with pancreaticoduodenectomy.

SUMMARY BACKGROUND DATA

Recent reports have suggested that preoperative biliary drainage increases the perioperative morbidity and mortality rates of pancreaticoduodenectomy.

METHODS

Peri-operative morbidity and mortality were evaluated in 300 consecutive patients who underwent pancreaticoduodenectomy. Univariate and multivariate logistic regression analyses were done to evaluate the relationship between preoperative biliary decompression and the following end points: any complication, any major complication, infectious complications, intraabdominal abscess, pancreaticojejunal anastomotic leak, wound infection, and postoperative death.

RESULTS

Preoperative prosthetic biliary drainage was performed in 172 patients (57%) (stent group), 35 patients (12%) underwent surgical biliary bypass performed during prereferral laparotomy, and the remaining 93 patients (31%) (no-stent group) did not undergo any form of preoperative biliary decompression. The overall surgical death rate was 1% (four patients); the number of deaths was too small for multivariate analysis. By multivariate logistic regression, no differences were found between the stent and no-stent groups in the incidence of all complications, major complications, infectious complications, intraabdominal abscess, or pancreaticojejunal anastomotic leak. Wound infections were more common in the stent group than the no-stent group.

CONCLUSIONS

Preoperative biliary decompression increases the risk for postoperative wound infections after pancreaticoduodenectomy. However, there was no increase in the risk of major postoperative complications or death associated with preoperative stent placement. Patients with extrahepatic biliary obstruction do not necessarily require immediate laparotomy to undergo pancreaticoduodenectomy with acceptable morbidity and mortality rates; such patients can be treated by endoscopic biliary drainage without concern for increased major complications and death associated with subsequent pancreaticoduodenectomy.

Preoperative chemoradiation therapy for pancreatic cancer

The authors present a critique of a fellow surgeon's version of multimodality therapy for patients with adenocarcinoma of the pancreas. Citing follow-up studies, the authors prescribe adjustments in therapeutic specifics to foster a more efficient approach to patients that results in lower toxicity and shorter treatment periods.

Pancreatic cancer

Optimal therapy for pancreatic adenocarcinoma requires surgical removal with tumor-free margins. Superior outcomes have been reported for high-volume centers incorporating a multidisciplinary approach. Postoperative ("adjuvant") chemotherapy and radiation should be considered in patients with successfully resected primary tumors. Combined modality treatment with chemotherapy and radiation should be considered for locally advanced, unresectable tumors. Gemcitabine can provide symptom relief and a modest improvement in survival for patients with metastatic disease. Strict attention to relief of symptoms such as pain, depression, anorexia/cachexia, and jaundice is essential in all patients with pancreatic cancer. All patients with pancreatic cancer should be encouraged to enter clinical trials of new therapies, given that long-term survival for all stages remains poor.

Novel non-operative treatment and treatment strategies in pancreatic cancer

Patients with advanced pancreatic cancer have traditionally been treated with palliative care only. The last decade has seen significant improvements in the surgical treatment of this disease but until the late 1990s there was no effective non-surgical treatment for these tumours. The introduction of gemcitabine has given clinicians treating patients with pancreatic cancer a new option. The published randomised data of gemcitabine in patients with pancreatic cancer has shown both a small survival advantage and significant improvements in quality of life indicators in these patients. These data have stimulated a resurgence of interest in pancreatic tumours and several studies have been or are currently investigating novel treatments or treatment strategies. The explosion in the molecular knowledge of cancer has led to the development of several 'molecular designer drugs' that have been tested in pancreatic cancer. The furthest advanced of these is a matrix metalloproteinase (MMP) inhibitor called marimastat. The first randomised data using this new class of agents is increasing and suggests that marimastat may have a role in the future treatment of patients with pancreatic cancer. Other agents such as gastrimmune, are about to enter Phase III studies and several other molecular treatment strategies are progressing from the in vitro stage towards the clinical arena. Each of these treatments and treatment regimens are discussed along with their current progress.