1
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Hoffe SE, Aguilera TA, Parikh PJ, Ghaly MM, Herman JM, Caster JM, Kim DW, Costello J, Malafa MP, Moser EC, Kennedy EP, Terry K, Kurman M. Stereotactic body radiotherapy plus rucosopasem in locally advanced or borderline resectable pancreatic cancer: GRECO-2 phase II study design. Future Oncol 2024; 20:437-446. [PMID: 38264869 PMCID: PMC10988540 DOI: 10.2217/fon-2022-1219] [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: 12/05/2022] [Accepted: 08/02/2023] [Indexed: 01/25/2024] Open
Abstract
Ablative doses of stereotactic body radiotherapy (SBRT) may improve pancreatic cancer outcomes but may carry greater potential for gastrointestinal toxicity. Rucosopasem, an investigational selective dismutase mimetic that converts superoxide to hydrogen peroxide, can potentially increase tumor control of SBRT without compromising safety. GRECO-2 is a phase II, multicenter, randomized, double-blind, placebo-controlled trial of rucosopasem in combination with SBRT in locally advanced or borderline resectable pancreatic cancer. Patients will be randomized to rucosopasem 100 mg or placebo via intravenous infusion over 15 min, before each SBRT fraction (5 × 10 Gy). The primary end point is overall survival. Secondary end points include progression-free survival, locoregional control, time to metastasis, surgical resection rate, best overall response, in-field local response and acute and long-term toxicity.
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Affiliation(s)
- Sarah E Hoffe
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | | | | | - Maged M Ghaly
- Northwell Health Cancer Institute, New Hyde Park, NY 11040, USA
| | - Joseph M Herman
- Northwell Health Cancer Institute, New Hyde Park, NY 11040, USA
| | - Joseph M Caster
- Universty of Iowa Hospitals & Clinics, Iowa City, IA 52242, USA
| | - Dae Won Kim
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - James Costello
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - Mokenge P Malafa
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | | | | | - Kara Terry
- Galera Therapeutics, Inc., Malvern, PA 19355, USA
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2
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Stoop TF, Theijse RT, Seelen LWF, Groot Koerkamp B, van Eijck CHJ, Wolfgang CL, van Tienhoven G, van Santvoort HC, Molenaar IQ, Wilmink JW, Del Chiaro M, Katz MHG, Hackert T, Besselink MG. Preoperative chemotherapy, radiotherapy and surgical decision-making in patients with borderline resectable and locally advanced pancreatic cancer. Nat Rev Gastroenterol Hepatol 2024; 21:101-124. [PMID: 38036745 DOI: 10.1038/s41575-023-00856-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2023] [Indexed: 12/02/2023]
Abstract
Surgical resection combined with systemic chemotherapy is the cornerstone of treatment for patients with localized pancreatic cancer. Upfront surgery is considered suboptimal in cases with extensive vascular involvement, which can be classified as either borderline resectable pancreatic cancer or locally advanced pancreatic cancer. In these patients, FOLFIRINOX or gemcitabine plus nab-paclitaxel chemotherapy is currently used as preoperative chemotherapy and is eventually combined with radiotherapy. Thus, more patients might reach 5-year overall survival. Patient selection for chemotherapy, radiotherapy and subsequent surgery is based on anatomical, biological and conditional parameters. Current guidelines and clinical practices vary considerably regarding preoperative chemotherapy and radiotherapy, response evaluation, and indications for surgery. In this Review, we provide an overview of the clinical evidence regarding disease staging, preoperative therapy, response evaluation and surgery in patients with borderline resectable pancreatic cancer or locally advanced pancreatic cancer. In addition, a clinical work-up is proposed based on the available evidence and guidelines. We identify knowledge gaps and outline a proposed research agenda.
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Affiliation(s)
- Thomas F Stoop
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, Netherlands
- Cancer Center Amsterdam, Amsterdam, Netherlands
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Rutger T Theijse
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, Netherlands
- Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Leonard W F Seelen
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus Medical Center, Rotterdam, Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus Medical Center, Rotterdam, Netherlands
| | - Christopher L Wolfgang
- Division of Surgical Oncology, Department of Surgery, New York University Medical Center, New York City, NY, USA
| | - Geertjan van Tienhoven
- Cancer Center Amsterdam, Amsterdam, Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Radiation Oncology, Amsterdam, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, Netherlands
| | - Johanna W Wilmink
- Cancer Center Amsterdam, Amsterdam, Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Medical Oncology, Amsterdam, Netherlands
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Marc G Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, Netherlands.
- Cancer Center Amsterdam, Amsterdam, Netherlands.
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3
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Daamen LA, Parikh PJ, Hall WA. The Use of MR-Guided Radiation Therapy for Pancreatic Cancer. Semin Radiat Oncol 2024; 34:23-35. [PMID: 38105090 DOI: 10.1016/j.semradonc.2023.10.002] [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: 12/19/2023]
Abstract
The introduction of online adaptive magnetic resonance (MR)-guided radiation therapy (RT) has enabled safe treatment of pancreatic cancer with ablative doses. The aim of this review is to provide a comprehensive overview of the current literature on the use and clinical outcomes of MR-guided RT for treatment of pancreatic cancer. Relevant outcomes included toxicity, tumor response, survival and quality of life. The results of these studies support further investigation of the effectiveness of ablative MR-guided SBRT as a low-toxic, minimally-invasive therapy for localized pancreatic cancer in prospective clinical trials.
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Affiliation(s)
- Lois A Daamen
- Imaging & Oncology Division, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Parag J Parikh
- Department of Radiation Oncology, Henry Ford Medical Center, Henry Ford Health System, Detroit, MI
| | - William A Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI.
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4
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Palm RF, Boyer E, Kim DW, Denbo J, Hodul PJ, Malafa M, Fleming JB, Shridhar R, Chuong MD, Mellon EA, Frakes JM, Hoffe SE. Neoadjuvant chemotherapy and stereotactic body radiation therapy for borderline resectable pancreas adenocarcinoma: influence of vascular margin status and type of chemotherapy. HPB (Oxford) 2023; 25:1110-1120. [PMID: 37286392 DOI: 10.1016/j.hpb.2023.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 01/29/2023] [Accepted: 04/30/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND The influence of chemotherapy type and vascular margin status after sequential chemotherapy and stereotactic body radiation therapy (SBRT) for borderline resectable pancreatic cancer (BRPC) is unknown. METHODS A retrospective review was performed on BRPC patients treated with chemotherapy and 5-fraction SBRT from 2009 to 2021. Surgical outcomes and SBRT-related toxicity were reported. Clinical outcomes were estimated by Kaplan-Meier with log rank comparisons. RESULTS A total of 303 patients received neoadjuvant chemotherapy and SBRT to a median dose of 40 Gy prescribed to the tumor-vessel interface and median dose of 32.4 Gyto 95% of the gross tumor volume. One hundred and sixty-nine patients (56%) were resected and benefited from improved median OS (41.1 vs 15.5 months, P < 0.001). Close/positive vascular margins were not associated with worse OS or FFLRF. Type of neoadjuvant chemotherapy did not influence OS for resected patients, but FOLFIRINOX was associated with improved median OS in unresected patients (18.2 vs 13.1 months, P = 0.001). CONCLUSION For BRPC, the effect of a positive or close vascular margin may be mitigated by neoadjuvant therapy. Shorter duration neoadjuvant chemotherapy as well as the optimal biological effective dose of radiotherapy should be prospectively explored.
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Affiliation(s)
- Russell F Palm
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa FL, USA.
| | - Emanuel Boyer
- University of South Florida School of Medicine, Tampa, FL, USA
| | - Dae W Kim
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa FL, USA
| | - Jason Denbo
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa FL, USA
| | - Pamela J Hodul
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa FL, USA
| | - Mokenge Malafa
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa FL, USA
| | - Jason B Fleming
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa FL, USA
| | - Ravi Shridhar
- Department of Radiation Oncology, Advent Health, Orlando, FL, USA
| | - Michael D Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami FL, USA
| | - Eric A Mellon
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA
| | - Jessica M Frakes
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa FL, USA
| | - Sarah E Hoffe
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa FL, USA
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5
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Springfeld C, Ferrone CR, Katz MHG, Philip PA, Hong TS, Hackert T, Büchler MW, Neoptolemos J. Neoadjuvant therapy for pancreatic cancer. Nat Rev Clin Oncol 2023; 20:318-337. [PMID: 36932224 DOI: 10.1038/s41571-023-00746-1] [Citation(s) in RCA: 71] [Impact Index Per Article: 71.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2023] [Indexed: 03/19/2023]
Abstract
Patients with localized pancreatic ductal adenocarcinoma (PDAC) are best treated with surgical resection of the primary tumour and systemic chemotherapy, which provides considerably longer overall survival (OS) durations than either modality alone. Regardless, most patients will have disease relapse owing to micrometastatic disease. Although currently a matter of some debate, considerable research interest has been focused on the role of neoadjuvant therapy for all forms of resectable PDAC. Whilst adjuvant combination chemotherapy remains the standard of care for patients with resectable PDAC, neoadjuvant chemotherapy seems to improve OS without necessarily increasing the resection rate in those with borderline-resectable disease. Furthermore, around 20% of patients with unresectable non-metastatic PDAC might undergo resection following 4-6 months of induction combination chemotherapy with or without radiotherapy, even in the absence of a clear radiological response, leading to improved OS outcomes in this group. Distinct molecular and biological responses to different types of therapies need to be better understood in order to enable the optimal sequencing of specific treatment modalities to further improve OS. In this Review, we describe current treatment strategies for the various clinical stages of PDAC and discuss developments that are likely to determine the optimal sequence of multimodality therapies by integrating the fundamental clinical and molecular features of the cancer.
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Affiliation(s)
- Christoph Springfeld
- Department of Medical Oncology, National Center for Tumour Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Philip A Philip
- Wayne State University School of Medicine, Department of Oncology, Henry Ford Cancer Institute, Detroit, MI, USA
| | - Theodore S Hong
- Research and Scientific Affairs, Gastrointestinal Service Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Thilo Hackert
- Department of General, Visceral and Thoracic Surgery, University hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - John Neoptolemos
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.
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6
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Hogg ME, Melstrom LG. Top Pancreatic Tumor Articles from 2021 to Inform Your Cancer Patients. Ann Surg Oncol 2023; 30:3437-3443. [PMID: 36917337 DOI: 10.1245/s10434-023-13277-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 02/12/2023] [Indexed: 03/15/2023]
Abstract
BACKGROUND More than 10,000 publications about pancreatic cancer were found on PubMed during the past year. METHODS To best inform patients with pancreatic cancer, the obvious, frequent questions asked during patient counseling when dealing with resectable pancreatic cancer, borderline resectable pancreatic cancer, and unresectable pancreatic cancer were considered. RESULTS The publications highlighted are comprehensive on the current management of neoadjuvant therapy for resectable pancreatic cancer, the addition of radiation to neoadjuvant therapy for borderline resectable pancreatic cancer, the utility of arterial resections in unresectable pancreatic cancer, and the role of minimally invasive approach to pancreatic cancer surgical therapy. CONCLUSION These articles are high yield and comprehensive review on key issues facing surgical oncologists who operate on pancreatic cancer.
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Affiliation(s)
- Melissa E Hogg
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA.
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7
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Hill CS, Herman JM. The Current Role of Radiation in Pancreatic Cancer and Future Directions. Clin Colorectal Cancer 2023; 22:12-23. [PMID: 36804206 DOI: 10.1016/j.clcc.2023.01.002] [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] [Received: 07/25/2022] [Revised: 12/15/2022] [Accepted: 01/24/2023] [Indexed: 02/01/2023]
Abstract
Survival outcomes for localized pancreatic adenocarcinoma remains poor. Multimodality therapeutic regimens are critical to maximizing survival outcomes for these patients, which includes the use of systemic therapy, surgery, and radiation. In this review, the evolution of radiation techniques are discussed with a focus on modern techniques such as intensity modulated radiation and stereotactic body radiation therapy. However, the current role of radiation within the most common clinical scenarios for pancreatic cancer in the neoadjuvant, definitive, and adjuvant settings continues to be highly debated. The role of radiation in these settings is reviewed in the context of historical and modern clinical studies. In addition, emerging concepts including dose-escalated radiation, magnetic resonance-guided radiation therapy, and particle therapy are discussed to promote an understanding of how such concepts may change the role of radiation in the future.
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Affiliation(s)
- Colin S Hill
- Department of Radiation Oncology, Perlmutter Cancer Center, New York University Grossman School of Medicine, New York, NY.
| | - Joseph M Herman
- Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, New York, NY
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8
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Saif A, Verbus E, Erickson B, Kamgar M, Tsai S, Evans D, Hernandez JM, Hall WA. A Randomized, Phase II, Clinical Trial of Preoperative Fractionated Radiation Therapy Versus Stereotactic Body Radiation Therapy for Resectable, Borderline Resectable, or Locally Advanced Type A Pancreatic Adenocarcinoma. Ann Surg Oncol 2023; 30:688-690. [PMID: 36427115 PMCID: PMC10688344 DOI: 10.1245/s10434-022-12742-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 10/17/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Areeba Saif
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Emily Verbus
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Beth Erickson
- Department of Radiation Oncology, Department of Surgery and the LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mandana Kamgar
- Department of Radiation Oncology, Department of Surgery and the LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Susan Tsai
- Department of Radiation Oncology, Department of Surgery and the LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Douglas Evans
- Department of Radiation Oncology, Department of Surgery and the LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jonathan M Hernandez
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - William A Hall
- Department of Radiation Oncology, Department of Surgery and the LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA.
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9
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Hall WA, Evans DB, Tsai S. Neoadjuvant mFOLFIRINOX vs mFOLFIRINOX Plus Radiotherapy in Patients With Borderline Resectable Pancreatic Cancer-The A021501 Trial. JAMA Oncol 2023; 9:275-276. [PMID: 36454556 DOI: 10.1001/jamaoncol.2022.6138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Affiliation(s)
- William A Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee.,Department of Surgical Oncology, Medical College of Wisconsin, Milwaukee
| | - Douglas B Evans
- Department of Surgical Oncology, Medical College of Wisconsin, Milwaukee
| | - Susan Tsai
- Department of Surgical Oncology, Medical College of Wisconsin, Milwaukee
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10
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Acuna-Villaorduna A, Shankar V, Wysota M, Jirgal A, Kabarriti R, Bellemare S, Goldman I, Kaubisch A, Aparo S, Goel S, Chuy J. Induction Chemotherapy With FOLFIRINOX Followed by Chemoradiation With Gemcitabine in Patients With Borderline-Resectable Pancreatic Ductal Adenocarcinoma. Cancer Control 2022; 29:10732748221134411. [PMID: 36221952 PMCID: PMC9558866 DOI: 10.1177/10732748221134411] [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] [Indexed: 11/25/2022] Open
Abstract
Introduction Perioperative therapy is standard for patients with borderline-resectable
pancreatic ductal adenocarcinoma (BR-PDAC); however, an optimal neoadjuvant
regimen is lacking. We assessed the efficacy of FOLFIRINOX chemotherapy
followed by gemcitabine-based chemoradiation as preoperative therapy. Methods Patients received 4 cycles of FOLFIRINOX, followed by 6-weekly gemcitabine
with concomitant intensity-modulated radiation. The primary endpoint was the
R0 resection rate. Secondary outcomes included resection rate,
overall-response, overall survival (OS), progression-free survival (PFS),
and tolerability. The trial was terminated early due to slow accrual. A
Simon’s optimal two-stage phase II trial single arm design was used. The
primary hypothesis of treatment efficacy was tested using a multistage group
sequential inference procedure. The secondary failure time analysis
endpoints were assessed using the Kaplan-Meier procedure and the Cox
regression model. Results A total of 22 patients enrolled in the study, 18 (81.8%) completed
neoadjuvant treatment. The bias corrected R0 rate was 55.6% (90% CI: 33.3,
68.3; P value = .16) among patients that received at least
1 cycle of FOLFIRINOX and was 80% among patients that underwent surgery. The
median OS was 35.1 months. The median PFS among patients that underwent
surgery was 34 months. Conclusion An R0 resection rate of 55.6% is favorable. Neoadjuvant FOLFIRINOX followed
by concomitant Gemcitabine with radiation was well-tolerated.
NCT01897454
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Affiliation(s)
- Ana Acuna-Villaorduna
- Department of Medical Oncology,
Montefiore
Medical Center, Bronx, NY, USA,Department of Medical Oncology,
Albert
Einstein College of Medicine, Bronx,
NY, USA
| | - Viswanathan Shankar
- Department of Epidemiology &
Population Health, Albert Einstein College of
Medicine, Bronx, NY, USA
| | - Michael Wysota
- Department of Medical Oncology,
Montefiore
Medical Center, Bronx, NY, USA,Department of Medical Oncology,
Albert
Einstein College of Medicine, Bronx,
NY, USA
| | - Amanda Jirgal
- Department of Medical Oncology,
Montefiore
Medical Center, Bronx, NY, USA
| | - Rafi Kabarriti
- Department of Radiation Oncology,
Montefiore
Medical Center, Bronx, NY, USA,Department of Radiation Oncology,
Albert
Einstein College of Medicine, Bronx,
NY, USA
| | - Sarah Bellemare
- Department of Surgery,
Montefiore
Medical Center, Bronx, NY, USA,Department of Surgery,
Albert
Einstein College of Medicine, Bronx,
NY, USA
| | - Inessa Goldman
- Department of Radiology,
Montefiore
Medical Center, Bronx, NY, USA,Department of Radiology,
Albert
Einstein College of Medicine, Bronx,
NY, USA
| | - Andreas Kaubisch
- Department of Medical Oncology,
Montefiore
Medical Center, Bronx, NY, USA,Department of Medical Oncology,
Albert
Einstein College of Medicine, Bronx,
NY, USA
| | - Santiago Aparo
- Department of Medical Oncology,
Montefiore
Medical Center, Bronx, NY, USA,Department of Medical Oncology,
Albert
Einstein College of Medicine, Bronx,
NY, USA
| | - Sanjay Goel
- Department of Medical Oncology,
Montefiore
Medical Center, Bronx, NY, USA,Department of Medical Oncology,
Albert
Einstein College of Medicine, Bronx,
NY, USA,Sanjay Goel, MD, MS, Professor of Medicine,
Department of Medical Oncology, Albert Einstein College of Medicine, Montefiore
Medical Center, 1695 Eastchester Road, Bronx NY 10461, USA.
; Jennifer Chuy, MD, Assistant
Professor of Medicine, Department of Medical Oncology, Albert Einstein College
of Medicine, Montefiore Medical Center, 1695 Eastchester Road, Bronx NY 10461,
USA.
| | - Jennifer Chuy
- Department of Medical Oncology,
Montefiore
Medical Center, Bronx, NY, USA,Department of Medical Oncology,
Albert
Einstein College of Medicine, Bronx,
NY, USA,Sanjay Goel, MD, MS, Professor of Medicine,
Department of Medical Oncology, Albert Einstein College of Medicine, Montefiore
Medical Center, 1695 Eastchester Road, Bronx NY 10461, USA.
; Jennifer Chuy, MD, Assistant
Professor of Medicine, Department of Medical Oncology, Albert Einstein College
of Medicine, Montefiore Medical Center, 1695 Eastchester Road, Bronx NY 10461,
USA.
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11
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Gray S, de Liguori Carino N, Radhakrishna G, Lamarca A, Hubner RA, Valle JW, McNamara MG. Clinical challenges associated with utility of neoadjuvant treatment in patients with pancreatic ductal adenocarcinoma. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:1198-1208. [PMID: 35264307 DOI: 10.1016/j.ejso.2022.02.014] [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: 01/04/2022] [Revised: 02/03/2022] [Accepted: 02/10/2022] [Indexed: 11/22/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an increasingly common cancer with a persistently poor prognosis, and only approximately 20% of patients are clearly anatomically resectable at diagnosis. Historically, a paucity of effective therapy made it inappropriate to forego the traditional gold standard of upfront surgery in favour of neoadjuvant treatment; however, modern combination chemotherapy regimens have made neoadjuvant therapy increasingly viable. As its use has expanded, the rationale for neoadjuvant therapy has evolved from one of 'downstaging' to one of early treatment of micro-metastases and selection of patients with favourable tumour biology for resection. Defining resectability in PDAC is problematic; multiple differing definitions exist. Multidisciplinary input, both in initial assessment of resectability and in supervision of multimodality therapy, is therefore advised. European and North American guidelines recommend the use of neoadjuvant chemotherapy in borderline resectable (BR)-PDAC. Similar regimens may be applied in locally advanced (LA)-PDAC with the aim of improving potential access to curative-intent resection, but appropriate patient selection is key due to significant rates of recurrence after excision of LA disease. Upfront surgery and adjuvant chemotherapy remain standard-of-care in clearly resectable PDAC, but multiple trials evaluating the use of neoadjuvant therapy in this and other localised settings are ongoing.
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Affiliation(s)
- Simon Gray
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd, Manchester, M20 4BX, United Kingdom
| | - Nicola de Liguori Carino
- Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Oxford Rd, Manchester, M13 9WL, United Kingdom
| | - Ganesh Radhakrishna
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd, Manchester, M20 4BX, United Kingdom
| | - Angela Lamarca
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd, Manchester, M20 4BX, United Kingdom; Division of Cancer Sciences, University of Manchester, Oxford Rd, Manchester, M13 9PL, United Kingdom
| | - Richard A Hubner
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd, Manchester, M20 4BX, United Kingdom; Division of Cancer Sciences, University of Manchester, Oxford Rd, Manchester, M13 9PL, United Kingdom
| | - Juan W Valle
- Division of Cancer Sciences, University of Manchester, Oxford Rd, Manchester, M13 9PL, United Kingdom; Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd, Manchester, M20 4BX, United Kingdom
| | - Mairéad G McNamara
- Division of Cancer Sciences, University of Manchester, Oxford Rd, Manchester, M13 9PL, United Kingdom; Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd, Manchester, M20 4BX, United Kingdom.
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12
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Novel Carbon Ion and Proton Partial Irradiation of Recurrent Unresectable Bulky Tumors (Particle-PATHY): Early Indication of Effectiveness and Safety. Cancers (Basel) 2022; 14:cancers14092232. [PMID: 35565361 PMCID: PMC9101845 DOI: 10.3390/cancers14092232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 04/26/2022] [Accepted: 04/28/2022] [Indexed: 02/04/2023] Open
Abstract
Background: We present the early results of a novel partial bulky-tumor irradiation using particles for patients with recurrent unresectable bulky tumors who failed previous state-of-the-art treatments. Methods: First, eleven consecutive patients were treated from March 2020 until December 2021. The targeted Bystander Tumor Volume (BTV) was created by subtracting 1 cm from Gross Tumor Volume (GTV) surface. It reflected approximately 30% of the central GTV volume and was irradiated with 30–45 Gy RBE (Relative Biological Effectiveness) in three consecutive fractions. The Peritumoral Immune Microenvironment (PIM) surrounding the GTV, containing nearby tissues, blood-lymphatic vessels and lymph nodes, was considered an organ at risk (OAR) and protected by highly conservative constraints. Results: With the median follow up of 6.3 months, overall survival was 64% with a median survival of 6.7 months; 46% of patients were progression-free. The average tumor volume regression was 61% from the initial size. The symptom control rate was 91%, with an average increase of the Karnofsky Index of 20%. The abscopal effect has been observed in 60% of patients. Conclusions: Partial bulky-tumor irradiation is an effective, safe and well tolerated treatment for patients with unresectable recurrent bulky disease. Abscopal effects elucidate an immunogenic pathway contribution. Extensive tumor shrinkage in some patients might permit definitive treatment—otherwise previously impossible.
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Xia N, Yang N, Shan Q, Wang Z, Liu X, Chen Y, Lu J, Huang W, Wang Z. HNRNPC regulates RhoA to induce DNA damage repair and cancer-associated fibroblast activation causing radiation resistance in pancreatic cancer. J Cell Mol Med 2022; 26:2322-2336. [PMID: 35277915 PMCID: PMC8995438 DOI: 10.1111/jcmm.17254] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 01/29/2022] [Accepted: 02/17/2022] [Indexed: 12/24/2022] Open
Abstract
Pancreatic cancer (PC) is one of the most lethal types of cancer due to its asymptomatic nature in the early stages and consequent late diagnosis. Its mortality rate remains high despite advances in treatment strategies, which include a combination of surgical resection and adjuvant therapy. Although these approaches may have a positive effect on prognosis, the development of chemo- and radioresistance still poses a significant challenge for successful PC treatment. Heterogeneous nuclear ribonucleoprotein C1/C2 (HNRNPC) and RhoA have been implicated in the regulation of tumour cell proliferation and chemo- and radioresistance. Our study aims to investigate the mechanism for HNRNPC regulation of PC radiation resistance via the RhoA pathway. We found that HNRNPC and RhoA mRNA and protein expression levels were significantly higher in PC tissues compared to adjacent non-tumour tissue. Furthermore, high HNRNPC expression was associated with poor patient prognosis. Using HNRNPC overexpression and siRNA interference, we demonstrated that HNRNPC overexpression promoted radiation resistance in PC cells, while HNRNPC knockdown increased radiosensitivity. However, silencing of RhoA expression was shown to attenuate radiation resistance caused by HNRNPC overexpression. Next, we identified RhoA as a downstream target of HNRNPC and showed that inhibition of the RhoA/ROCK2-YAP/TAZ pathway led to a reduction in DNA damage repair and radiation resistance. Finally, using both in vitro assays and an in vivo subcutaneous tumour xenograft model, we demonstrated that RhoA inhibition can hinder the activity of cancer-related fibroblasts and weaken PC radiation resistance. Our study describes a role for HNRNPC and the RhoA/ROCK2-YAP/TAZ signalling pathways in mediating radiation resistance and provides a potential therapeutic target for improving the treatment of PC.
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Affiliation(s)
- Ning Xia
- Department of RadiologyRuijin Hospital Luwan BranchShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Nannan Yang
- Department of RadiologyRuijin Hospital Luwan BranchShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Qungang Shan
- Department of Interventional RadiologyRuijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Ziyin Wang
- Department of Interventional RadiologyRuijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Xiaoyu Liu
- Department of Interventional RadiologyRuijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Yingjie Chen
- Department of Interventional RadiologyRuijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Jian Lu
- Department of RadiologyRuijin Hospital Luwan BranchShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Wei Huang
- Department of Interventional RadiologyRuijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Zhongmin Wang
- Department of RadiologyRuijin Hospital Luwan BranchShanghai Jiao Tong University School of MedicineShanghaiChina
- Department of Interventional RadiologyRuijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
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Targeting STAT3 Signaling Facilitates Responsiveness of Pancreatic Cancer Cells to Chemoradiotherapy. Cancers (Basel) 2022; 14:cancers14051301. [PMID: 35267609 PMCID: PMC8908974 DOI: 10.3390/cancers14051301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 02/24/2022] [Accepted: 02/27/2022] [Indexed: 02/05/2023] Open
Abstract
The debate is ongoing regarding the potential role of preoperative chemoradiotherapy (CRT) for patients with pancreatic ductal adenocarcinoma (PDAC), and whether it should be reserved for borderline resectable or unresectable tumors. However, treatment response is heterogeneous, implicating the need to unveil and overcome the underlying mechanisms of resistance. Activation of the transcription factor STAT3 was recently linked to CRT resistance in other gastrointestinal cancers such as rectal and esophageal cancers, but its role in PDAC needs to be clarified. Protein expression and phosphorylation of STAT3 was determined in PDAC cell lines and connected to transcriptional activity measured by dual-luciferase reporter gene assays. Inhibition of STAT3 signaling was achieved by RNAi or the small-molecule inhibitor napabucasin. We observed a positive correlation between STAT3 signaling activity and CRT resistance. Importantly, genetical and pharmacological perturbation of the IL-6/STAT3 pathway resulted in CRT sensitization specifically in those cell lines, in which STAT3 activity was augmented by IL-6. In conclusion, our data underscore the general importance of IL-6/STAT3 signaling for CRT resistance and suggest that pathway inhibition may represents a putative treatment strategy in order to increase the fraction of patients with PDAC who are candidates for surgical approaches.
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Neoadjuvant Therapy Is Associated with Improved Chemotherapy Delivery and Overall Survival Compared to Upfront Resection in Pancreatic Cancer without Increasing Perioperative Complications. Cancers (Basel) 2022; 14:cancers14030609. [PMID: 35158877 PMCID: PMC8833799 DOI: 10.3390/cancers14030609] [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: 12/21/2021] [Revised: 01/15/2022] [Accepted: 01/23/2022] [Indexed: 11/17/2022] Open
Abstract
The role of neoadjuvant chemoradiotherapy and/or chemotherapy (neoCHT) in patients with pancreatic ductal adenocarcinoma (PDAC) is poorly defined. We hypothesized that patients who underwent neoadjuvant therapy (NAT) would have improved systemic therapy delivery, as well as comparable perioperative complications, compared to patients undergoing upfront resection. This is an IRB-approved retrospective study of potentially resectable PDAC patients treated within an academic quaternary referral center between 2011 and 2018. Data were abstracted from the electronic medical record using an institutional cancer registry and the National Surgical Quality Improvement Program. Three hundred and fourteen patients were eligible for analysis and eighty-one patients received NAT. The median overall survival (OS) was significantly improved in patients who received NAT (28.6 vs. 20.1 months, p = 0.014). Patients receiving neoCHT had an overall increased mean duration of systemic therapy (p < 0.001), and the median OS improved with each month of chemotherapy delivered (HR = 0.81 per month CHT, 95% CI (0.76-0.86), p < 0.001). NAT was not associated with increases in early severe post-operative complications (p = 0.47), late leaks (p = 0.23), or 30-90 day readmissions (p = 0.084). Our results show improved OS in patients who received NAT, driven largely by improved chemotherapy delivery, without an apparent increase in early or late perioperative complications compared to patients undergoing upfront resection.
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