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Goetze TO, Reichart A, Bankstahl US, Pauligk C, Loose M, Kraus TW, Elshafei M, Bechstein WO, Trojan J, Behrend M, Homann N, Venerito M, Bohle W, Varvenne M, Bolling C, Behringer DM, Kratz-Albers K, Siegler GM, Hozaeel W, Al-Batran SE. Adjuvant Gemcitabine Versus Neoadjuvant/Adjuvant FOLFIRINOX in Resectable Pancreatic Cancer: The Randomized Multicenter Phase II NEPAFOX Trial. Ann Surg Oncol 2024; 31:4073-4083. [PMID: 38459418 PMCID: PMC11076394 DOI: 10.1245/s10434-024-15011-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 01/21/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Although addition of adjuvant chemotherapy is the current standard, the prognosis of pancreatic cancers still remains poor. The NEPAFOX trial evaluated perioperative treatment with FOLFIRINOX in resectable pancreatic cancer. PATIENTS AND METHODS This multicenter phase II trial randomized patients with resectable or borderline resectable pancreatic cancer without metastases into arm (A,) upfront surgery plus adjuvant gemcitabine, or arm (B,) perioperative FOLFIRINOX. The primary endpoint was overall survival (OS). RESULTS Owing to poor accrual, recruitment was prematurely stopped after randomization of 40 of the planned 126 patients (A: 21, B: 19). Overall, approximately three-quarters were classified as primarily resectable (A: 16, B: 15), and the remaining patients were classified as borderline resectable (A: 5, B: 4). Of the 12 evaluable patients, 3 achieved partial response under neoadjuvant FOLFIRINOX. Of the 21 patients in arm A and 19 patients in arm B, 17 and 7 underwent curative surgery, and R0-resection was achieved in 77% and 71%, respectively. Perioperative morbidity occurred in 72% in arm A and 46% in arm B, whereas non-surgical toxicity was comparable in both arms. Median RFS/PFS was almost doubled in arm B (14.1 months) compared with arm A (8.4 months) in the population with surgical resection, whereas median OS was comparable between both arms. CONCLUSIONS Although the analysis was only descriptive owing to small patient numbers, no safety issues regarding surgical complications were observed in the perioperative FOLFIRINOX arm. Thus, considering the small number of patients, perioperative treatment approach appears feasible and potentially effective in well-selected cohorts of patients. In pancreatic cancer, patient selection before initiation of neoadjuvant therapy appears to be critical.
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Affiliation(s)
- Thorsten O Goetze
- Krankenhaus Nordwest, Institut für Klinisch Onkologische Forschchung IKF, University Cancer Center (UCT) Frankfurt, Frankfurt, Germany.
- University Cancer Center (UCT) Frankfurt, Goethe Universität, Frankfurt, Germany.
- Frankfurter Institut für Klinische Krebsforschung IKF am Krankenhaus Nordwest, Frankfurt, Germany.
| | - Alexander Reichart
- Krankenhaus Nordwest, Institut für Klinisch Onkologische Forschchung IKF, University Cancer Center (UCT) Frankfurt, Frankfurt, Germany
| | - Ulli S Bankstahl
- Krankenhaus Nordwest, Institut für Klinisch Onkologische Forschchung IKF, University Cancer Center (UCT) Frankfurt, Frankfurt, Germany
| | - Claudia Pauligk
- Frankfurter Institut für Klinische Krebsforschung IKF am Krankenhaus Nordwest, Frankfurt, Germany
| | - Maria Loose
- Frankfurter Institut für Klinische Krebsforschung IKF am Krankenhaus Nordwest, Frankfurt, Germany
| | - Thomas W Kraus
- Krankenhaus Nordwest, Allgemein-, Viszeral- und Minimal Invasive Chirurgie, Frankfurt, Germany
| | - Moustafa Elshafei
- Krankenhaus Nordwest, Allgemein-, Viszeral- und Minimal Invasive Chirurgie, Frankfurt, Germany
| | - Wolf O Bechstein
- Klinik für Allgemein-, Viszeral-, Transplantations- und Thoraxchirurgie, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - Jörg Trojan
- Gastrointestinale Onkologie, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - Matthias Behrend
- Viszeral-, Thorax- und Gefäßchirurgie, DONAUISAR Klinikum Deggendorf, Deggendorf, Germany
| | - Nils Homann
- Medizinische Klinik II, Klinikum Wolfsburg, Wolfsburg, Germany
| | - Marino Venerito
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Magdeburg, Magdeburg, Germany
| | - Wolfram Bohle
- Klinik für Gastroenterologie, Gastroenterologische Onkologie, Klinikum Stuttgart, Stuttgart, Germany
- Hepatologie, Infektiologie und Pneumologie, Stuttgart, Germany
| | | | - Claus Bolling
- Hämatologie/Onkologie, Agaplesion Markus Krankenhaus, Frankfurt, Germany
| | - Dirk M Behringer
- Klinik für Hämatologie, Onkologie und Palliativmedizin, Augusta-Kranken-Anstalt Bochum, Bochum, Germany
| | | | - Gabriele M Siegler
- Klinikum Nürnberg Nord/Paracelsus Medizinische Privatuniversität, Medizinische Klinik, Hämatologie/Onkologie, Nürnberg, Germany
| | - Wael Hozaeel
- Krankenhaus Nordwest, Institut für Klinisch Onkologische Forschchung IKF, University Cancer Center (UCT) Frankfurt, Frankfurt, Germany
| | - Salah-Eddin Al-Batran
- Krankenhaus Nordwest, Institut für Klinisch Onkologische Forschchung IKF, University Cancer Center (UCT) Frankfurt, Frankfurt, Germany
- University Cancer Center (UCT) Frankfurt, Goethe Universität, Frankfurt, Germany
- Frankfurter Institut für Klinische Krebsforschung IKF am Krankenhaus Nordwest, Frankfurt, Germany
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Kolbeinsson HM, Chandana S, Wright GP, Chung M. Pancreatic Cancer: A Review of Current Treatment and Novel Therapies. J INVEST SURG 2023; 36:2129884. [PMID: 36191926 DOI: 10.1080/08941939.2022.2129884] [Citation(s) in RCA: 98] [Impact Index Per Article: 98.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Pancreatic cancer is one of the leading causes for cancer-related deaths in the United States. Majority of patients present with unresectable or metastatic disease. For those that present with localized disease, a multidisciplinary approach is necessary to maximize survival and optimize outcomes. The quality and safety of surgery for pancreatic cancer have improved in recent years with increasing adoption of minimally invasive techniques and surgical adjuncts. Systemic chemotherapy has also evolved to impact survival. It is now increasingly being utilized in the neoadjuvant setting, often with concomitant radiation. Increased utilization of genomic testing in metastatic pancreatic cancer has led to better understanding of their biology, thereby allowing clinicians to consider potential targeted therapies. Similarly, targeted agents such as PARP inhibitors and immune checkpoint- inhibitors have emerged with promising results. In summary, pancreatic cancer remains a disease with poor long-term survival. However, recent developments have led to improved outcomes and have changed practice in the past decade. This review summarizes current practices in pancreatic cancer treatment and the milestones that brought us to where we are today, along with emerging therapies.
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Affiliation(s)
- Hordur Mar Kolbeinsson
- Spectrum Health General Surgery Residency, Grand Rapids, Michigan, USA.,Department of Surgery, Michigan State University College of Human Medicine, Grand Rapids, Michigan, USA
| | - Sreenivasa Chandana
- Department of Surgery, Michigan State University College of Human Medicine, Grand Rapids, Michigan, USA.,Cancer and Hematology Centers of Western Michigan, PC, Grand Rapids, Michigan, USA
| | - G Paul Wright
- Spectrum Health General Surgery Residency, Grand Rapids, Michigan, USA.,Department of Surgery, Michigan State University College of Human Medicine, Grand Rapids, Michigan, USA.,Division of Surgical Oncology, Spectrum Health Medical Group, Grand Rapids, Michigan, USA
| | - Mathew Chung
- Spectrum Health General Surgery Residency, Grand Rapids, Michigan, USA.,Department of Surgery, Michigan State University College of Human Medicine, Grand Rapids, Michigan, USA.,Division of Surgical Oncology, Spectrum Health Medical Group, Grand Rapids, Michigan, USA
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3
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Cassese G, Han HS, Yoon YS, Lee JS, Lee B, Cubisino A, Panaro F, Troisi RI. Role of neoadjuvant therapy for nonmetastatic pancreatic cancer: Current evidence and future perspectives. World J Gastrointest Oncol 2023; 15:911-924. [PMID: 37389109 PMCID: PMC10302990 DOI: 10.4251/wjgo.v15.i6.911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/17/2023] [Accepted: 04/24/2023] [Indexed: 06/14/2023] Open
Abstract
Pancreatic adenocarcinoma (PDAC) is one of the most common and lethal human cancers worldwide. Surgery followed by adjuvant chemotherapy offers the best chance of a long-term survival for patients with PDAC, although only approximately 20% of the patients have resectable tumors when diagnosed. Neoadjuvant chemotherapy (NACT) is recommended for borderline resectable pancreatic cancer. Several studies have investigated the role of NACT in treating resectable tumors based on the recent advances in PDAC biology, as NACT provides the potential benefit of selecting patients with favorable tumor biology and controls potential micro-metastases in high-risk patients with resectable PDAC. In such challenging cases, new potential tools, such as ct-DNA and molecular targeted therapy, are emerging as novel therapeutic options that may improve old paradigms. This review aims to summarize the current evidence regarding the role of NACT in treating non-metastatic pancreatic cancer while focusing on future perspectives in light of recent evidence.
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Affiliation(s)
- Gianluca Cassese
- Department of Clinical Medicine and Surgery, Division of Minimally Invasive HPB Surgery and Transplantation Service, Federico II University Hospital, Naples 80131, Italy
| | - Ho-Seong Han
- Department of Surgery, Seoul National University College of Medicine, Seongnam 13620, Gyeonggi-do, South Korea
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University College of Medicine, Seongnam 13620, Gyeonggi-do, South Korea
| | - Jun Suh Lee
- Department of Surgery, Seoul National University College of Medicine, Seongnam 13620, Gyeonggi-do, South Korea
| | - Boram Lee
- Department of Surgery, Seoul National University College of Medicine, Seongnam 13620, Gyeonggi-do, South Korea
| | - Antonio Cubisino
- Department of HPB Surgery and Transplantation, Beaujon Hospital, Clichy 92110, France
| | - Fabrizio Panaro
- Department of Digestive Surgery and Liver Transplantation, CHU Montpellier, Montpellier 34100, France
| | - Roberto Ivan Troisi
- Department of Clinical Medicine and Surgery, Division of Minimally Invasive HPB Surgery and Transplantation Service, Federico II University Hospital, Naples 80131, Italy
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Amr B, MacCormick A, Miles G, Shahtahmassebi G, Roobottom C, Stell D. Estimation of the organ of origin of peri-ampullary malignancy by preoperative CT scan. Acta Radiol 2023; 64:891-897. [PMID: 35593447 DOI: 10.1177/02841851221096284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Tumors occurring within the pancreatic head commonly arise from the pancreas, duodenal ampulla, distal bile duct, or duodenum. However, they are difficult to distinguish on standard preoperative imaging. PURPOSE To assess the ability of specialist reporting of preoperative computed tomography (CT) scans to determine the organ of origin of pancreatic cancer (PC). MATERIAL AND METHODS Blinded re-reporting of preoperative imaging from five hospitals was undertaken of a consecutive cohort of 411 patients undergoing surgery for PC between January 2006 and May 2014. Radiological identification of tumor site was determined by the presence of the main tumor bulk within the pancreatic head parenchyma and estimation of the pathological organ of origin of the PC was based on all the reported features. RESULTS Each pathological tumor type was noted to have distinct radiological features. Localization of a visible tumor within the pancreatic parenchyma was seen most commonly in PC (92%) than other tumor types (P < 0.0001). Local invasion into the duodenum was a characteristic feature seen in 79% of patients with ampullary tumors and isolated dilation of the bile duct without dilation of the pancreatic duct was seen most commonly in patients with ampullary or bile duct cancer. In the assessment of tumor origin, good agreement (kappa = 0.6, 0.51-0.68) was noted between the consensus radiology opinion and the final histology result. Overall accuracy was greatest for ampullary cancer (88.1%) and lowest for PC (83.2%). CONCLUSION Radiological assessment of preoperative imaging provides a high degree of accuracy in predicting the organ of origin of peri-ampullary cancer.
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Affiliation(s)
- Bassem Amr
- 6634University Hospitals Plymouth NHS Trust, Derriford Hospital, Plymouth, UK
| | - Andrew MacCormick
- 6634University Hospitals Plymouth NHS Trust, Derriford Hospital, Plymouth, UK
| | - Gemma Miles
- 6634University Hospitals Plymouth NHS Trust, Derriford Hospital, Plymouth, UK
| | | | - Carl Roobottom
- 6634University Hospitals Plymouth NHS Trust, Derriford Hospital, Plymouth, UK
| | - David Stell
- 6634University Hospitals Plymouth NHS Trust, Derriford Hospital, Plymouth, UK
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5
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Walpole I, Lee B, Shapiro J, Thomson B, Lipton L, Ananda S, Usatoff V, Mclachlan SA, Knowles B, Fox A, Wong R, Cooray P, Burge M, Clarke K, Pattison S, Nikfarjam M, Tebbutt N, Harris M, Nagrial A, Zielinski R, Chee CE, Gibbs P. Use and outcomes from neoadjuvant chemotherapy in borderline resectable pancreatic ductal adenocarcinoma in an Australasian population. Asia Pac J Clin Oncol 2023; 19:214-225. [PMID: 35831999 DOI: 10.1111/ajco.13807] [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: 01/25/2022] [Revised: 05/08/2022] [Accepted: 06/13/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Use of neoadjuvant (NA) chemotherapy is recommended when pancreatic ductal adenocarcinoma (PDAC) is borderline resectable METHOD: A retrospective analysis of consecutive patients with localized PDAC between January 2016 and March 2019 within the Australasian Pancreatic Cancer Registry (PURPLE, Pancreatic cancer: Understanding Routine Practice and Lifting End results) was performed. Clinicopathological characteristics, treatment, and outcome were analyzed. Overall survival (OS) comparison was performed using log-rank model and Kaplan-Meier analysis. RESULTS The PURPLE database included 754 cases with localised PDAC, including 148 (20%) cases with borderline resectable pancreatic cancer (BRPC). Of the 148 BRPC patients, 44 (30%) underwent immediate surgery, 80 (54%) received NA chemotherapy, and 24 (16%) were inoperable. The median age of NA therapy patients was 63 years and FOLFIRINOX (53%) was more often used as NA therapy than gemcitabine/nab-paclitaxel (31%). Patients who received FOLFIRINOX were younger than those who received gemcitabine/nab-paclitaxel (60 years vs. 67 years, p = .01). Surgery was performed in 54% (43 of 80) of BRPC patients receiving NA chemotherapy, with 53% (16 of 30) achieving R0 resections. BRPC patients undergoing surgery had a median OS of 30 months, and 38% (9 of 24) achieved R0 resection. NA chemotherapy patients had a median OS of 20 months, improving to 24 months versus 10 months for patients receiving FOLFIRINOX compared to gemcitabine/nab-paclitaxel (Hazard Ratio (HR) .3, p < .0001). CONCLUSIONS NA chemotherapy use in BRPC is increasing in Australia. One half of patients receiving NA chemotherapy proceed to curative resection, with 53% achieving R0 resections. Patients receiving Infusional 5-flurouracil, Irinotecan and Oxaliplatin (FOLIRINOX) had increased survival than gemcitabine/nab-paclitaxel. Treatment strategies are being explored in the MASTERPLAN and DYNAMIC-Pancreas trials.
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Affiliation(s)
- Imogen Walpole
- Department of Medical Oncology, Northern Hospital, Victoria, Australia
| | - Belinda Lee
- Department of Medical Oncology, Northern Hospital, Victoria, Australia
- Walter and Eliza Hall Institute, Melbourne, Victoria, Australia
- Faculty of Medicine & Health Sciences, Faculty fo Medicine University of Melbourne, Victoria, Australia
| | - Jeremy Shapiro
- Department of Medical Oncology, Cabrini Health, Malvern, Victoria, Australia
- Faculty of Medicine & Health Sciences, Monash University, Victoria, Australia
| | - Benjamin Thomson
- Department of Surgery, University of Melbourne, Royal Melbourne Hospital, Victoria, Australia
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Victoria, Australia
| | - Lara Lipton
- Department of Medical Oncology, Cabrini Health, Malvern, Victoria, Australia
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Victoria, Australia
- Department of Medical Oncology, Western Health, Victoria, Australia
| | - Sumitra Ananda
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Victoria, Australia
- Department of Medical Oncology, Western Health, Victoria, Australia
| | - Val Usatoff
- Department of Medical Oncology, Cabrini Health, Malvern, Victoria, Australia
- Department of Medical Oncology, Western Health, Victoria, Australia
| | - Sue-Ann Mclachlan
- Faculty of Medicine & Health Sciences, Faculty fo Medicine University of Melbourne, Victoria, Australia
- Department of Medical Oncology, St Vincent's Hospital, Victoria, Australia
| | - Brett Knowles
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Victoria, Australia
- Department of Medical Oncology, St Vincent's Hospital, Victoria, Australia
| | - Adrian Fox
- Department of Medical Oncology, St Vincent's Hospital, Victoria, Australia
- Department of Medical Oncology, Eastern Health, Victoria, Australia
| | - Rachel Wong
- Walter and Eliza Hall Institute, Melbourne, Victoria, Australia
- Faculty of Medicine & Health Sciences, Monash University, Victoria, Australia
- Department of Medical Oncology, Eastern Health, Victoria, Australia
- Department of Medical Oncology, Epworth Hospital, Victoria, Australia
| | - Prasad Cooray
- Department of Medical Oncology, Knox Private Hospital, Victoria, Australia
| | - Matthew Burge
- Department of Medical Oncology, Royal Brisbane Hospital, Queensland, Australia
| | - Kate Clarke
- Department of Medical Oncology, Wellington Hospital, Wellington, New Zealand
| | - Sharon Pattison
- Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Mehrdad Nikfarjam
- Faculty of Medicine & Health Sciences, Faculty fo Medicine University of Melbourne, Victoria, Australia
- Department of Medical Oncology, Austin Health, Victoria, Australia
- Department of Surgery, Warringal Private Hospital, Victoria, Australia
| | - Niall Tebbutt
- Department of Medical Oncology, Austin Health, Victoria, Australia
| | - Marion Harris
- Department of Medical Oncology, Monash Medical Centre, Victoria, Australia
| | - Adnan Nagrial
- Department of Medical Oncology, Westmead Hospital, New South Wales, Australia
| | - Rob Zielinski
- Department of Medical Oncology, Orange Hospital, New South Wales, Australia
- Department of Medical Oncology, Dubbo Base Hospital, New South Wales, Australia
- Department of Medical Oncology, Bathurst Base Hospital, New South Wales, Australia
| | - Cheng Ean Chee
- Department of Medical Oncology, National University Cancer Institute, Singapore
| | - Peter Gibbs
- Walter and Eliza Hall Institute, Melbourne, Victoria, Australia
- Faculty of Medicine & Health Sciences, Faculty fo Medicine University of Melbourne, Victoria, Australia
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Luo W, Wang Y, Tao Y, Zhang T. Is neoadjuvant chemoradiotherapy for pancreatic cancer beneficial: A systematic review and meta-analysis. Front Oncol 2022; 12:979390. [PMID: 36505795 PMCID: PMC9727153 DOI: 10.3389/fonc.2022.979390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 10/17/2022] [Indexed: 11/24/2022] Open
Abstract
To examine the potential benefits and adverse events of neoadjuvant Chemoradiotherapy (CRT) versus upfront surgery in pancreatic cancer (PC) patients. Extensive librarian-led literature searches were conducted on PubMed, Web-of-Science, Scopus, Google Scholar, the Cochrane Central Library and Embase. The primary outcomes were resectability, adverse events, pathological and survival outcomes. Five studies, including 437 participants, were analyzed. Upfront surgery had a significantly higher resectability among PC patients than neoadjuvant CRT group (Odds ratio = -0.11, 95% CI = -0.19-0.02, P = 0.01). The neoadjuvant CRT group had a comparatively higher Ro resection rate (OR = 3.38, 95% CI = 2.03-5.62, P < 0.01), fewer severe adverse events(OR = 0.56, 95% CI = 0.34-0.92, P = 0.02), lower positive LN rate(OR = 0.18, 95% CI = 0.11-0.31, P < 0.01) and higher 2-year OS(OR = 1.60, 95% CI = 1.02-2.52, P = 0.04) among PC patients than control group. There was no significant difference between neoadjuvant CRT and upfront surgery among PC patients on postoperative complications(OR = 1.49, 95% CI = 0.86-2.57, P = 0.16), metastasis rate(OR = 1.32, 95% CI = 0.42-4.18, P = 0.64) and 1-year OS(OR = 1.30, 95% CI = 0.85-1.98, P = 0.22). This systematic review confirmed the status of neoadjuvant CRT in the PC treatment. The neoadjuvant CRT could increase the R0 resection rate, which was important to the survival and life quality of patients. The specific choice of various neoadjuvant CRT therapy needs to be further studied. Individualized neoadjuvant therapy should be suitable for each patient, and patients with PC are best managed by a multidisciplinary team.
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Affiliation(s)
- Wenhao Luo
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yawen Wang
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yinjie Tao
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Taiping Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China,*Correspondence: Taiping Zhang,
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7
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Zhang HQ, Li J, Tan CL, Chen YH, Zheng ZJ, Liu XB. Neoadjuvant therapy in resectable pancreatic cancer: A promising curative method to improve prognosis. World J Gastrointest Oncol 2022; 14:1903-1917. [PMID: 36310705 PMCID: PMC9611436 DOI: 10.4251/wjgo.v14.i10.1903] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 08/05/2022] [Accepted: 09/07/2022] [Indexed: 02/05/2023] Open
Abstract
Currently, 15 randomized controlled trials (RCTs) have been designed to investigate whether neoadjuvant therapy (NAT) benefits patients with resectable pancreatic adenocarcinoma (R-PA) compared to surgery alone. Five of them have acquired results so far; however, corresponding conclusions have not been obtained. We speculated that the reason for this phenomenon could be that some prognostic factors had proven to be adverse through upfront surgery curative patterns, but some of them were not regarded as independent baseline characteristics, which is important to obtaining comparability between the NAT and upfront surgery groups. This fact could cause bias and lead to the difference in the outcomes of RCTs. In this review, we collate data about risk factors (such as tumor size, resection margin, and lymph node status) influencing the prognoses of patients with R-PA from five RCTs and discuss the possible reasons for the varying outcomes.
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Affiliation(s)
- Hao-Qi Zhang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Jing Li
- Department of Operating Room/West China School of Nursing, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Chun-Lu Tan
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Yong-Hua Chen
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Zhen-Jiang Zheng
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Xu-Bao Liu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
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8
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Puleo A, Malla M, Boone BA. Defining the Optimal Duration of Neoadjuvant Therapy for Pancreatic Ductal Adenocarcinoma: Time for a Personalized Approach? Pancreas 2022; 51:1083-1091. [PMID: 37078929 PMCID: PMC10144367 DOI: 10.1097/mpa.0000000000002147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 11/03/2022] [Indexed: 04/21/2023]
Abstract
ABSTRACT Despite recent advances, pancreatic ductal adenocarcinoma (PDAC) continues to be associated with dismal outcomes, with a cure evading most patients. While historic treatment for PDAC has been surgical resection followed by 6 months of adjuvant therapy, there has been a recent shift toward neoadjuvant treatment (NAT). Several considerations support this approach, including the characteristic early systemic spread of PDAC, and the morbidity often surrounding pancreatic resection, which can delay recovery and preclude patients from starting adjuvant treatment. The addition of NAT has been suggested to improve margin-negative resection rates, decrease lymph node positivity, and potentially translate to improved survival. Conversely, complications and disease progression can occur during preoperative treatment, potentially eliminating the chance of curative resection. As NAT utilization has increased, treatment durations have been found to vary widely between institutions with an optimal duration remaining undefined. In this review, we assess the existing literature on NAT for PDAC, reviewing treatment durations reported across retrospective case series and prospective clinical trials to establish currently used approaches and seek the optimal duration. We also analyze markers of treatment response and review the potential for personalized approaches that may help clarify this important treatment question and move NAT toward a more standardized approach.
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Affiliation(s)
- Amanda Puleo
- From the Division of Surgical Oncology, Department of Surgery
| | - Midhun Malla
- Section of Hematology/Oncology, Department of Medicine
| | - Brian A. Boone
- From the Division of Surgical Oncology, Department of Surgery
- Department of Microbiology, Immunology and Cell Biology, West Virginia University, Morgantown, WV
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Wang C, Tan G, Zhang J, Fan B, Chen Y, Chen D, Yang L, Chen X, Duan Q, Maimaiti F, Du J, Lin Z, Gu J, Luo H. Neoadjuvant Therapy for Pancreatic Ductal Adenocarcinoma: Where Do We Go? Front Oncol 2022; 12:828223. [PMID: 35785193 PMCID: PMC9245892 DOI: 10.3389/fonc.2022.828223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 05/09/2022] [Indexed: 11/15/2022] Open
Abstract
The incidence of pancreatic ductal adenocarcinoma (PDAC) has been on the rise in recent years; however, its clinical diagnosis and treatment remain challenging. Although surgical resection remains the only chance for long-term patient survival, the likelihood of initial resectability is no higher than 20%. Neoadjuvant therapy (NAT) in PDAC aims to transform the proportion of inoperable PDACs into operable cases and reduce the likelihood of recurrence to improve overall survival. Ongoing phase 3 clinical trial aims to validate the role of NAT in PDAC therapy, including prolongation of survival, increased R0 resection, and a higher proportion of negative lymph nodes. Controversies surrounding the role of NAT in PDAC treatment include applicability to different stages of PDAC, chemotherapy regimens, radiation, duration of treatment, and assessment of effect. This review aims to summarize the current progress and controversies of NAT in PDAC.
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Affiliation(s)
- Chenqi Wang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Guang Tan
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jie Zhang
- Department of Oncology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Bin Fan
- Department of General Surgery, The First Hospital of Northwest University (Xi’an No. 1 Hospital), Xi’an, China
| | - Yunlong Chen
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Dan Chen
- Department of Pathology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Lili Yang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xiang Chen
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Qingzhu Duan
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Feiliyan Maimaiti
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jian Du
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Zhikun Lin
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jiangning Gu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, China
- *Correspondence: Haifeng Luo, ; Jiangning Gu,
| | - Haifeng Luo
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, China
- *Correspondence: Haifeng Luo, ; Jiangning Gu,
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10
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Versteijne E, de Hingh IHJT, Homs MYV, Intven MPW, Klaase JM, van Santvoort HC, de Vos-Geelen J, Wilmink JW, van Tienhoven G. Neoadjuvant Treatment for Resectable and Borderline Resectable Pancreatic Cancer: Chemotherapy or Chemoradiotherapy? Front Oncol 2022; 11:744161. [PMID: 35237500 PMCID: PMC8882845 DOI: 10.3389/fonc.2021.744161] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 12/30/2021] [Indexed: 12/12/2022] Open
Abstract
Worldwide, there is a shifting paradigm from immediate surgery with adjuvant treatment to a neoadjuvant approach for patients with resectable or borderline resectable pancreatic cancer (RPC or BRPC). Comparison of neoadjuvant and adjuvant studies is extremely difficult because of a great difference in patient selection. The evidence from randomized studies shows that overall survival by intention-to-treat improves after neoadjuvant gemcitabine-based chemoradiotherapy or chemotherapy (various regimens), as compared to immediate surgery followed by adjuvant chemotherapy. Radiotherapy appears to play an important role in mediating locoregional effects. Yet, since more effective chemotherapy regimens are currently available, in particular FOLFIRINOX and Gemcitabine/Nab-paclitaxel, these chemotherapy regimens should be investigated in future randomized trials combined with (stereotactic) radiotherapy to further improve outcomes of RPC and BRPC.
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Affiliation(s)
- Eva Versteijne
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam University Medical Center (UMC), University of Amsterdam, Amsterdam, Netherlands
| | - Ignace H. J. T. de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven and GROW—School for Oncology and Developmental Biology, Maastricht University, Maastricht, Netherlands
| | - Marjolein Y. V. Homs
- Department Medical Oncology, Erasmus Medical Center (MC) Cancer Institute, Rotterdam, Netherlands
| | - Martijn P. W. Intven
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Joost M. Klaase
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, Netherlands
| | - Hjalmar C. van Santvoort
- Department of Surgery, Regionaal Academisch Kankercentrum Utrecht (RAKU), St Antonius Hospital, Nieuwegein, Netherlands
| | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW—School for Oncology and Developmental Biology, Maastricht University Medical Center (UMC+), Maastricht, Netherlands
| | - Johanna W. Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Center (UMC), University of Amsterdam, Amsterdam, Netherlands
| | - Geertjan van Tienhoven
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam University Medical Center (UMC), University of Amsterdam, Amsterdam, Netherlands
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11
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Long-Term Outcome of Patients with Postoperative Refractory Diarrhea After Tailored Nerve Plexus Dissection Around the Major Visceral Arteries During Pancreatoduodenectomy for Pancreatic Cancer. World J Surg 2022; 46:1172-1182. [PMID: 35119513 DOI: 10.1007/s00268-022-06457-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND For pancreatic ductal adenocarcinoma (PDAC) surgery, extended dissection of the nerve plexus (pl) around the superior mesenteric artery (SMA) or celiac artery (CA) is sometimes necessary. This consequently results in postoperative refractory diarrhea. This study aimed to evaluate the clinical impact of extended nerve plexus dissection around major arteries on postoperative diarrhea. METHODS Patients who underwent pancreatoduodenectomy (PD) for PDAC between January 2013 and December 2016 were included. The frequency of diarrhea (defined as a condition requiring opioid antidiarrheal drug for at least 6 months after surgery) and its short- and long-term outcomes were reviewed. RESULTS Of 200 consecutive patients who underwent PD, 78 (39.0%) developed postoperative refractory diarrhea (diarrhea group), and 73 of them (93.6%) underwent hemi-circumferential or more nerve dissection for SMA or CA; both plSMA and plCA dissection were associated with diarrhea. Borderline resectable artery (BR-A) PDAC was included more in the diarrhea group (32.0% vs. 13.1%, P = 0.001); however, the local recurrence rate in the diarrhea group was significantly lower than that in the non-diarrhea group (14.1% vs. 26.2%, P = 0.036). The completion of adjuvant chemotherapy and overall survival were comparable between the two groups. The pre-albumin level improved in 2 years, and 61.3% of patients with diarrhea could stop opioid antidiarrheal drugs within 3 years of surgery. CONCLUSIONS Although the frequency of diarrhea increased following nerve plexus dissection around arteries, diarrhea was controllable and resulted in a reduced local recurrence rate. Aggressive dissection of the nerve plexus may be justified for local disease control in BR-A PDAC.
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12
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Ward EP, Zeh Iii HJ, Tsai S. Current Controversies in Neoadjuvant Therapy for Pancreatic Cancer. Surg Oncol Clin N Am 2021; 30:657-671. [PMID: 34511188 DOI: 10.1016/j.soc.2021.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Over the last two decades, there have been significant changes in the management of patients with localized pancreatic cancer. The rationale for an evolution toward a neoadjuvant approach and summary of relevant clinical trials is reviewed. Controversies in identifying optimal neoadjuvant therapeutic approaches are discussed.
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Affiliation(s)
- Erin P Ward
- Surgical Oncology Division, Department of Surgery, Medical College of Wisconsin, 8701 W Watertown Plank Road, Milwaukee, WI 53226, USA
| | - Herbert J Zeh Iii
- Division of Surgical Oncology, Department of Surgery, UT Southwestern (University of Texas), 5323 Harry Hines Blvd. Dallas, TX 75390, USA
| | - Susan Tsai
- Surgical Oncology Division, Department of Surgery, Medical College of Wisconsin, 8701 W Watertown Plank Road, Milwaukee, WI 53226, USA.
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13
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Taboada AGM, Lominchar PL, Roman LM, García-Alfonso P, Martin AJM, Rodriguez JAB, Pascual JMA. Advances in neoadjuvant therapy for resectable pancreatic cancer over the past two decades. Ann Hepatobiliary Pancreat Surg 2021; 25:179-191. [PMID: 34053920 PMCID: PMC8180394 DOI: 10.14701/ahbps.2021.25.2.179] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/31/2020] [Indexed: 02/06/2023] Open
Abstract
In the last two decades, pancreatic cancer has been undergoing important changes in its perioperative management due to the great interest in multidisciplinary management and preoperative multimodal therapy, which in numerous studies have shown promising clinical results. Although the standard of treatment for resectable pancreatic ductal adenocarcinoma (PDAC) today is surgery followed by adjuvant therapy, as it is a biologically aggressive disease, even with complete resection, it has high rates of local and distant relapse. Several retrospective and prospective phase I/II studies have opened the window for neoadjuvant therapy with chemotherapy (CT), chemoradiotherapy (CRT), or both, as an alternative treatment for resectable pancreatic cancer, with promising results. Neoadjuvant therapy could has some advantages, including early administration of systemic treatment, in vivo assessment of response to treatment, increase resectability rate in borderline patients, increase resection rate with negative margin and survival benefit. While it seems clear that even potentially resectable disease would benefit from preoperative multimodal therapy, the optimal neoadjuvant therapeutic strategy is still controversial and currently there are only recommendations for neoadjuvant treatment, in clinical guidelines such as the NCCN and ESMO, for borderline and/or locally advanced PDAC. This review provides an overview of recent studies available and how they relate to systemic treatment of resectable PDAC in the neoadjuvant setting.
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Affiliation(s)
- Alvaro Gregorio Morales Taboada
- Department of General and Digestive Surgery, Hospital General Universitario Gregorio Marañon, Complutense University of Madrid, Madrid, Spain.,Transplant and Hepatobiliopancreatic Surgery Unit, Department of General and Digestive Surgery, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Pablo Lozano Lominchar
- Department of General and Digestive Surgery, Hospital General Universitario Gregorio Marañon, Complutense University of Madrid, Madrid, Spain
| | - Lorena Martin Roman
- Department of General and Digestive Surgery, Hospital General Universitario Gregorio Marañon, Complutense University of Madrid, Madrid, Spain
| | - Pilar García-Alfonso
- Department of Medical Oncology, Department of Oncology, Hospital general Universitario Gregorio Marañon, Complutense University of Madrid, Madrid, Spain
| | - Andres Jesús Muñoz Martin
- Department of Medical Oncology, Department of Oncology, Hospital general Universitario Gregorio Marañon, Complutense University of Madrid, Madrid, Spain
| | - Jose Antonio Blanco Rodriguez
- Department of Radiation Oncology, Department of Oncology, Hospital general Universitario Gregorio Marañon, Complutense University of Madrid, Madrid, Spain
| | - Jose Manuel Asencio Pascual
- Department of General and Digestive Surgery, Hospital General Universitario Gregorio Marañon, Complutense University of Madrid, Madrid, Spain.,Transplant and Hepatobiliopancreatic Surgery Unit, Department of General and Digestive Surgery, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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14
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Huguet F, Rivin Del Campo E, Labidi M, Ménard J, Sergent G, Durand B, Quéro L. Cancers gastriques et pancréatiques : la (chimio)radiothérapie néoadjuvante remplacera-t-elle la chimioradiothérapie adjuvante ? Cancer Radiother 2020; 24:493-500. [DOI: 10.1016/j.canrad.2020.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 05/24/2020] [Accepted: 05/28/2020] [Indexed: 12/24/2022]
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15
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Affiliation(s)
- Kristin N Kelly
- Division of Surgical Oncology, Dewitt-Daughtry Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 Northwest 14th Street, CRB, 4th Floor, Miami, FL 33136, USA
| | - Francisco I Macedo
- Department of Surgery, North Florida Regional Medical Center, University of Central Florida College of Medicine, Gainesville, FL, USA
| | - Nipun B Merchant
- Division of Surgical Oncology, Dewitt-Daughtry Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 Northwest 14th Street, CRB, 4th Floor, Miami, FL 33136, USA.
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16
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Patterns of Failure After Neoadjuvant Stereotactic Body Radiation Therapy or Fractionated Chemoradiation in Resectable and Borderline Resectable Pancreatic Cancer. Pancreas 2020; 49:941-946. [PMID: 32658077 DOI: 10.1097/mpa.0000000000001602] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The goal of this study was to compare outcomes of patients with borderline and resectable pancreatic cancer treated with neoadjuvant stereotactic body radiation therapy (SBRT) versus fractionated chemoradiation. METHODS Patients with borderline or resectable pancreatic cancer treated with neoadjuvant intent between November 2011 and December 2017 were reviewed. The SBRT volume/dose was 33 Gy in 5 fractions to gross tumor plus abutting vessel with or without 25 Gy in 5 fractions to pancreatic head/body and celiac/superior mesenteric artery. Fractionated chemoradiation volume/dose was 50.4 Gy in 28 fractions to gross tumor, superior mesenteric/celiac arteries, and enlarged lymph nodes with concurrent bolus 5-FU, leucovorin, oxaliplatin, irinotecan or gemcitabine/nab-paclitaxel. Failure patterns, local recurrence-free survival (LRFS), progression-free survival (PFS), and overall survival were assessed. RESULTS Forty-three patients were reviewed (18 SBRTs and 25 fractionated). Among patients who underwent resection, patients treated with fractionated chemoradiation had improved LRFS (12-month LRFS, 86% vs 62%, P = 0.003) and PFS (median PFS, 23 months vs 11 months, P = 0.006) compared with SBRT. There was no difference in overall survival. CONCLUSIONS Stereotactic body radiation therapy may result in inferior LRFS and PFS compared with fractionated chemoradiation, likely because of under coverage of high-risk vascular targets.
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17
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Azab B, Macedo FI, Chang D, Ripat C, Franceschi D, Livingstone AS, Yakoub D. The Impact of Prolonged Chemotherapy to Surgery Interval and Neoadjuvant Radiotherapy on Pathological Complete Response and Overall Survival in Pancreatic Cancer Patients. CLINICAL MEDICINE INSIGHTS-ONCOLOGY 2020; 14:1179554920919402. [PMID: 32669884 PMCID: PMC7336830 DOI: 10.1177/1179554920919402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 03/04/2020] [Indexed: 01/15/2023]
Abstract
Background: We aimed to study the impact of neoadjuvant chemotherapy to surgery (NCT-S)
interval and neoadjuvant radiotherapy (NRT) on pathological complete
response (pCR) and overall survival (OS) in pancreatic cancer (pancreatic
ductal adenocarcinoma [PDAC]). Methods: National Cancer Data Base (NCDB)–pancreatectomy patients who underwent
NCT/NRT were included. The NCT-S interval was divided into time quintiles in
weeks: 8 to 11, 12 to 14, 15 to 19, 20 to 29, and >29 weeks. Results: A total of 2093 patients with NCT were included with median follow-up of
74 months and 71% NRT. The pCR rate was 2.1% with higher median OS compared
with non-pCR (41 vs 19 months, P = .03). The pCR rate
increased with longer NCT-S interval (quintiles: 1%, 1.6%, 1.7%, 3%, and 6%,
P < .001, respectively). In logistic regression, NRT
(odds ratio [OR] = 2.5, 95% confidence interval [CI]: 1.1-6.1,
P = .03) and NCT-S >29 weeks (OR = 6.1, 95%
CI = 2.02-18.50, P < .001) were predictive of increased
pCR. The prolonged NCT-S interval and pCR were independent predictors of OS,
whereas NRT was not. Conclusions: Longer NCT-S interval and pCR were independent predictors of improved OS in
patients with PDAC. The NRT predicted increased pCR but not OS.
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Affiliation(s)
- Basem Azab
- Surgical Oncology, Sentara Healthcare, Sentara CarePlex Hospital, Hampton, VA, USA
| | - Francisco Igor Macedo
- Surgical Oncology, DeWitt Daughtry Family Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - David Chang
- Virginia Oncology Associate, Hampton, VA, USA
| | - Caroline Ripat
- Surgical Oncology, DeWitt Daughtry Family Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Dido Franceschi
- Surgical Oncology, DeWitt Daughtry Family Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Alan S Livingstone
- Surgical Oncology, DeWitt Daughtry Family Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Danny Yakoub
- Surgical Oncology, DeWitt Daughtry Family Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
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18
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Motoi F, Unno M. Adjuvant and neoadjuvant treatment for pancreatic adenocarcinoma. Jpn J Clin Oncol 2020; 50:483-489. [PMID: 32083290 DOI: 10.1093/jjco/hyaa018] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/21/2020] [Accepted: 01/28/2020] [Indexed: 02/06/2023] Open
Abstract
The prognosis of pancreatic adenocarcinoma is dismal. Hence, advances in multidisciplinary treatment strategies, including surgery, are urgently needed. Early recurrence of distant organ metastases suggests that there are occult metastases even in cases with resectable disease. Several randomized controlled trials on adjuvant chemotherapy have been conducted to prolong survival after resection. CONKO-001 study was the first to demonstrate significant improvement in disease-free survival after surgery with gemcitabine administration. The JASPAC-01 study showed the superiority of adjuvant S1 over gemcitabine in survival after resection. Based on the results, adjuvant S1 therapy is the prescribed standard of care in Japan. Recently, the PRODIGE 24/CCTG PA.6 study showed that survival of patients treated with a modified FOLFIRINOX regimen as adjuvant therapy was significantly longer than those treated with adjuvant gemcitabine therapy. Although the evidence from these trials on adjuvant chemotherapy have been the gold-standard treatment for curatively resected and fully recovered patients, resectable disease at diagnosis is not the status, resected disease after curative resection. Currently, neoadjuvant therapy is considered to be a promising alternative to surgery for pancreatic cancer. Although there are many reports regarding neoadjuvant chemoradiotherapy, so far there has been no solid evidence proving the advantage of this strategy versus standard up-front surgery. Newly obtained results from the Prep-02/JSAP05 randomized phase II/III study, comparing neoadjuvant therapy with up-front surgery, revealed significant improvement in overall survival with neoadjuvant chemotherapy by intention-to-treat analysis. Thus, neoadjuvant intervention might become a new standard strategy in cases undergoing planned resection for pancreatic cancer.
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Affiliation(s)
- Fuyuhiko Motoi
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
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19
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Mapping transient hypoxia from in situ activation of 15O by photon beams: A simulation study. Radiat Phys Chem Oxf Engl 1993 2020. [DOI: 10.1016/j.radphyschem.2020.108815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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20
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Motoi F, Unno M. Neoadjuvant treatment for resectable pancreatic adenocarcinoma: What is the best protocol? Ann Gastroenterol Surg 2020; 4:100-108. [PMID: 32258974 PMCID: PMC7105839 DOI: 10.1002/ags3.12311] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 11/27/2019] [Accepted: 12/16/2019] [Indexed: 12/13/2022] Open
Abstract
Although upfront surgery has been the gold standard for pancreatic adenocarcinoma that is planned for resection, it should be compared with the alternative strategy of neoadjuvant therapy. Despite the many reports of the efficacy of neoadjuvant therapy, most of them were not comparative. Recently Prep-02/JSAP05 study clearly demonstrated the significant survival benefit of neoadjuvant chemotherapy over upfront surgery for pancreatic adenocarcinoma that is planned for resection. These findings opened a new chapter of neoadjuvant therapy. Ongoing trials are expected to confirm the evidence. This review summarizes the past, present, and future perspectives of neoadjuvant therapy and its optimization.
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Affiliation(s)
- Fuyuhiko Motoi
- Department of SurgeryTohoku University Graduate School of MedicineAoba‐kuJapan
| | - Michiaki Unno
- Department of SurgeryTohoku University Graduate School of MedicineAoba‐kuJapan
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21
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Oba A, Ho F, Bao QR, Al-Musawi MH, Schulick RD, Del Chiaro M. Neoadjuvant Treatment in Pancreatic Cancer. Front Oncol 2020; 10:245. [PMID: 32185128 PMCID: PMC7058791 DOI: 10.3389/fonc.2020.00245] [Citation(s) in RCA: 136] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 02/13/2020] [Indexed: 12/13/2022] Open
Abstract
Thanks to the development of modern chemotherapeutic regimens, survival after surgery for pancreatic ductal adenocarcinoma (PDAC) has improved and pancreatologists worldwide agree that the treatment of PDAC demands a multidisciplinary approach. Neoadjuvant treatment (NAT) plays a major role in the treatment of PDAC since only about 20% of patients are considered resectable at the time of diagnosis. Moreover, increasing data demonstrating the benefits of NAT for borderline resectable/locally advanced PDAC are driving a shift from up-front surgery to NAT in the multidisciplinary treatment of even resectable PDAC. Our understanding of the role of NAT in PDAC has evolved from tumor shrinkage to controlling potential micrometastases and selecting patients who may benefit from radical resection. The present review gives an overview on the current literature of NAT concepts for BR/LA PDAC and resectable PDAC.
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Affiliation(s)
- Atsushi Oba
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Denver, CO, United States.,Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Felix Ho
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Denver, CO, United States
| | - Quoc Riccardo Bao
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Denver, CO, United States.,Department of Surgery, Oncology, and Gastroenterology, University of Padua, Padua, Italy
| | - Mohammed H Al-Musawi
- Clinical Trials Office, Department of Surgery, University of Colorado, Anschutz Medical Campus, Denver, CO, United States
| | - Richard D Schulick
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Denver, CO, United States
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Denver, CO, United States
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22
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Versteijne E, Suker M, Groothuis K, Akkermans-Vogelaar JM, Besselink MG, Bonsing BA, Buijsen J, Busch OR, Creemers GJM, van Dam RM, Eskens FALM, Festen S, de Groot JWB, Groot Koerkamp B, de Hingh IH, Homs MYV, van Hooft JE, Kerver ED, Luelmo SAC, Neelis KJ, Nuyttens J, Paardekooper GMRM, Patijn GA, van der Sangen MJC, de Vos-Geelen J, Wilmink JW, Zwinderman AH, Punt CJ, van Eijck CH, van Tienhoven G. Preoperative Chemoradiotherapy Versus Immediate Surgery for Resectable and Borderline Resectable Pancreatic Cancer: Results of the Dutch Randomized Phase III PREOPANC Trial. J Clin Oncol 2020; 38:1763-1773. [PMID: 32105518 PMCID: PMC8265386 DOI: 10.1200/jco.19.02274] [Citation(s) in RCA: 634] [Impact Index Per Article: 158.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Preoperative chemoradiotherapy may improve the radical resection rate for resectable or borderline resectable pancreatic cancer, but the overall benefit is unproven. PATIENTS AND METHODS In this randomized phase III trial in 16 centers, patients with resectable or borderline resectable pancreatic cancer were randomly assigned to receive preoperative chemoradiotherapy, which consisted of 3 courses of gemcitabine, the second combined with 15 × 2.4 Gy radiotherapy, followed by surgery and 4 courses of adjuvant gemcitabine or to immediate surgery and 6 courses of adjuvant gemcitabine. The primary end point was overall survival by intention to treat. RESULTS Between April 2013 and July 2017, 246 eligible patients were randomly assigned; 119 were assigned to preoperative chemoradiotherapy and 127 to immediate surgery. Median overall survival by intention to treat was 16.0 months with preoperative chemoradiotherapy and 14.3 months with immediate surgery (hazard ratio, 0.78; 95% CI, 0.58 to 1.05; P = .096). The resection rate was 61% and 72% (P = .058). The R0 resection rate was 71% (51 of 72) in patients who received preoperative chemoradiotherapy and 40% (37 of 92) in patients assigned to immediate surgery (P < .001). Preoperative chemoradiotherapy was associated with significantly better disease-free survival and locoregional failure-free interval as well as with significantly lower rates of pathologic lymph nodes, perineural invasion, and venous invasion. Survival analysis of patients who underwent tumor resection and started adjuvant chemotherapy showed improved survival with preoperative chemoradiotherapy (35.2 v 19.8 months; P = .029). The proportion of patients who suffered serious adverse events was 52% versus 41% (P = .096). CONCLUSION Preoperative chemoradiotherapy for resectable or borderline resectable pancreatic cancer did not show a significant overall survival benefit. Although the outcomes of the secondary end points and predefined subgroup analyses suggest an advantage of the neoadjuvant approach, additional evidence is required.
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Affiliation(s)
- Eva Versteijne
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Mustafa Suker
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Karin Groothuis
- Clinical Research Department, Comprehensive Cancer Organisation the Netherlands (IKNL), Nijmegen, the Netherlands
| | - Janine M Akkermans-Vogelaar
- Clinical Research Department, Comprehensive Cancer Organisation the Netherlands (IKNL), Nijmegen, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Jeroen Buijsen
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Ronald M van Dam
- Department of Surgery, Division of Hepato-Pancreato-Biliary & Oncology, European Surgery Center Aachen Maastricht, Maastricht UMC+, Maastricht, the Netherlands
| | - Ferry A L M Eskens
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Sebastiaan Festen
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Marjolein Y V Homs
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Emile D Kerver
- Department of Medical Oncology, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - Saskia A C Luelmo
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Karen J Neelis
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Joost Nuyttens
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | | | - Gijs A Patijn
- Department of Surgery, Isala Oncology Center, Zwolle, the Netherlands
| | | | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW School for Oncology and Developmental Biology, Maastricht UMC+, Maastricht, the Netherlands
| | - Johanna W Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Aeilko H Zwinderman
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Cornelis J Punt
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Geertjan van Tienhoven
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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23
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Araujo RLC, Silva RO, de Pádua Souza C, Milani JM, Huguet F, Rezende AC, Gaujoux S. Does neoadjuvant therapy for pancreatic head adenocarcinoma increase postoperative morbidity? A systematic review of the literature with meta-analysis. J Surg Oncol 2020; 121:881-892. [PMID: 31994193 DOI: 10.1002/jso.25851] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 01/09/2020] [Indexed: 12/11/2022]
Abstract
Neoadjuvant treatment (NT) for pancreatic head cancer may allow some patients to undergo curative resection, but its impact on postoperative complications remains unclear. A systematic review and meta-analysis were performed to compare overall postoperative morbidity, pancreatic fistula, and mortality between patients who underwent upfront surgery and those who underwent neoadjuvant therapy first. Forty-five studies with 3359 patients were included. No significant differences in morbidity and mortality rates associated with NT for pancreatic head cancer were detected in this study.
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Affiliation(s)
- Raphael L C Araujo
- Department of Digestive Surgery, Escola Paulista de Medicina (UNIFESP), São Paulo, São Paulo, Brazil.,Post-graduation Program, Barretos Cancer Hospital, Barretos, São Paulo, Brazil.,Department of Oncology, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | - Raphael O Silva
- Department of Surgical Oncology, Hospital Santa Casa, Campo Mourão, Paraná, Brazil
| | | | - Jean M Milani
- Post-graduation Program, Barretos Cancer Hospital, Barretos, São Paulo, Brazil
| | - Florence Huguet
- Department of Radiation Oncology, Hôpital Tenon AP-HP, Sorbonne University, Paris, France
| | - Ana C Rezende
- Department of Oncology, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | - Sebastien Gaujoux
- Department of Digestive, Pancreatic and Endocrine Surgery, Hôpital Cochin AP-HP, Paris, France
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24
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Tran NH, Sahai V, Griffith KA, Nathan H, Kaza R, Cuneo KC, Shi J, Kim E, Sonnenday CJ, Cho CS, Lawrence TS, Zalupski MM. Phase 2 Trial of Neoadjuvant FOLFIRINOX and Intensity Modulated Radiation Therapy Concurrent With Fixed-Dose Rate-Gemcitabine in Patients With Borderline Resectable Pancreatic Cancer. Int J Radiat Oncol Biol Phys 2020; 106:124-133. [PMID: 31494181 PMCID: PMC7245020 DOI: 10.1016/j.ijrobp.2019.08.057] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 08/11/2019] [Accepted: 08/26/2019] [Indexed: 01/05/2023]
Abstract
PURPOSE Preoperative therapy in borderline resectable pancreatic cancer (BRPC) is intended to increase R0 resection rates. An optimal approach in BRPC is yet to be defined. METHODS AND MATERIALS Patients with BRPC, confirmed adenocarcinoma, performance status ≤1, and adequate organ function enrolled in a single-institution, phase 2 trial. Patients received FOLFIRINOX × 6 cycles, then radiation therapy (50 Gy in 25 fractions) concurrent with fixed-dose rate gemcitabine (1 g/m2 over 100 minutes) followed by 2 additional gemcitabine infusions. Computed tomography scans were performed at 2-month intervals during treatment. Patients without distant disease were offered surgical exploration. The primary objective was R0 resection rate with an alternate hypothesis of 55%. Secondary objectives included median progression-free survival (PFS), median overall survival (OS), response rate, and safety. The trial registration number is NCT01661088. RESULTS Twenty-five patients with median age of 60 years (range, 47-77 years) enrolled from November 2011 through January 2017. Twenty-one (84%) completed FOLFIRINOX and 19 (76%) completed all protocol therapy. Treatment-related grade 3 to 4 toxicities included neutropenia (40%), nausea and vomiting (28%), diarrhea (16%), and fatigue (12%). Eighteen patients (72%) underwent laparotomy, 13 (52%) were resected (all R0). The median PFS and OS in 25 patients were 13.1 months (95% confidence interval [CI], 7.3-24.7) and 24.4 months (95% CI, 12.6-40.0), respectively. For resected patients, median PFS was 21.6 months (95% CI, 8.2-37.1) and OS was 37.1 months (95% CI, 15.4-not reached). CONCLUSIONS Neoadjuvant therapy with FOLFIRINOX, followed by intensity modulated radiation therapy concurrent with fixed-dose-rate gemcitabine in BRPC is feasible and tolerated. Although the alternate hypothesis was not met, the OS of the resected cohort was favorable.
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Affiliation(s)
| | | | | | | | - Ravi Kaza
- University of Michigan, Ann Arbor, Michigan
| | | | - Jiaqi Shi
- University of Michigan, Ann Arbor, Michigan
| | - Edward Kim
- Work completed at University of Michigan. Currently at University of California, Davis, California
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Vidri RJ, Vogt AO, Macgillivray DC, Bristol IJ, Fitzgerald TL. Better Defining the Role of Total Neoadjuvant Radiation: Changing Paradigms in Locally Advanced Pancreatic Cancer. Ann Surg Oncol 2019; 26:3701-3708. [DOI: 10.1245/s10434-019-07584-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Indexed: 02/06/2023]
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26
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Piątek M, Kuśnierz K, Bieńkowski M, Pęksa R, Kowalczyk M, Nawrocki S. Primarily resectable pancreatic adenocarcinoma - to operate or to refer the patient to an oncologist? Crit Rev Oncol Hematol 2019; 135:95-102. [PMID: 30819452 DOI: 10.1016/j.critrevonc.2019.01.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 01/12/2019] [Accepted: 01/21/2019] [Indexed: 12/13/2022] Open
Abstract
The aim of this work is to investigate the optimal therapeutic sequence of resectable pancreatic cancer - primary surgery with adjuvant therapy or neoadjuvant followed by resection. Application of the neoadjuvant approach in routine treatment of pancreatic cancer is rapidly growing every year, despite the lack of final results from randomized trials. Recent advancements in the adjuvant therapy, due to the more effective chemotherapy regimens, favor the upfront surgery strategy. On the other hand, theoretical background and metaanalyses favor the neoadjuvant strategy. Currently, primary resection with adjuvant chemotherapy remains the standard approach in resectable pancreatic cancer, but the first recommendations considering the neoadjuvant approach as an option seem to arise among the scientific societies with a global impact. Preliminary results of Prodige 24 study and PREOPANC-1 trial demonstrates that both options are worth further evaluation in clinical trials. Their results should soon provide more answers to this important clinical questions.
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Affiliation(s)
- Michał Piątek
- Department of Oncology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Katarzyna Kuśnierz
- Department of Gastrointestinal Surgery, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | | | - Rafał Pęksa
- Department of Patomorphology, Medical University of Gdańsk, Poland
| | - Marek Kowalczyk
- Department of Radiotherapy, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Sergiusz Nawrocki
- Department of Radiotherapy, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland
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27
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Bradley A, Van Der Meer R. Neoadjuvant therapy versus upfront surgery for potentially resectable pancreatic cancer: A Markov decision analysis. PLoS One 2019; 14:e0212805. [PMID: 30817807 PMCID: PMC6394923 DOI: 10.1371/journal.pone.0212805] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 02/09/2019] [Indexed: 12/16/2022] Open
Abstract
Background Neoadjuvant therapy has emerged as an alternative treatment strategy for potentially resectable pancreatic cancer. In the absence of large randomized controlled trials offering a direct comparison, this study aims to use Markov decision analysis to compare efficacy of traditional surgery first (SF) and neoadjuvant treatment (NAT) pathways for potentially resectable pancreatic cancer. Methods An advanced Markov decision analysis model was constructed to compare SF and NAT pathways for potentially resectable pancreatic cancer. Transition probabilities were calculated from randomized control and Phase II/III trials after comprehensive literature search. Utility outcomes were measured in overall and quality-adjusted life months (QALMs) on an intention-to-treat basis as the primary outcome. Markov cohort analysis of treatment received was the secondary outcome. Model uncertainties were tested with one and two-way deterministic and probabilistic Monte Carlo sensitivity analysis. Results SF gave 23.72 months (18.51 QALMs) versus 20.22 months (16.26 QALMs). Markov Cohort Analysis showed that where all treatment modalities were received NAT gave 35.05 months (29.87 QALMs) versus 30.96 months (24.86QALMs) for R0 resection and 34.08 months (29.87 QALMs) versus 25.85 months (20.72 QALMs) for R1 resection. One-way deterministic sensitivity analysis showed that NAT was superior if the resection rate was greater than 51.04% or below 75.68% in SF pathway. Two-way sensitivity analysis showed that pathway superiority depended on obtaining multimodal treatment in either pathway. Conclusion Whilst NAT is a viable alternative to traditional SF approach, superior pathway selection depends on the individual patient’s likelihood of receiving multimodal treatment in either pathway.
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Affiliation(s)
- Alison Bradley
- Department of Management Science, Strathclyde Business School, University of Strathclyde, Glasgow, Scotland, United Kingdom
- West of Scotland Pancreatic Cancer Unit, Glasgow Royal Infirmary, Glasgow, Scotland, United Kingdom
- * E-mail:
| | - Robert Van Der Meer
- Department of Management Science, Strathclyde Business School, University of Strathclyde, Glasgow, Scotland, United Kingdom
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28
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Outcomes after neoadjuvant treatment with gemcitabine and erlotinib followed by gemcitabine-erlotinib and radiotherapy for resectable pancreatic cancer (GEMCAD 10-03 trial). Cancer Chemother Pharmacol 2018; 82:935-943. [PMID: 30225601 DOI: 10.1007/s00280-018-3682-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 08/27/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Neoadjuvant therapy (NAT) for pancreatic adenocarcinoma (PDAC) patients has shown promising results in non-randomized trials. This is a multi-institutional phase II trial of NAT in resectable PDAC patients. METHODS Patients with confirmed resectable PDAC after agreement by two expert radiologists were eligible. Patients received three cycles of GEM (1000 mg/m2/week) plus daily erlotinib (ERL) (100 mg/day). After re-staging, patients without progressive disease underwent 5 weeks of therapy with GEM (300 mg/m2/week), ERL 100 mg/day and concomitant radiotherapy (45 Gy). Efficacy was assessed using tumor regression grade (TRG) and resection margin status. Using a single-arm Simon's design, considering the therapy not useful if R0 < 40% and useful if the R0 > 70% (alpha 5%, beta 10%), 24 patients needed to be recruited. This trial was registered at ClinicalTrials.gov, number NCT01389440. RESULTS Twenty-five patients were enrolled. Adverse effects of NAT were mainly mild gastrointestinal disorders. Resectability rate was 76%, with a R0 rate of 63.1% among the resected patients. Median overall survival (OS) and disease-free survival (DFS) were 23.8 (95% CI 11.4-36.2) and 12.8 months (95% CI 8.6-17.1), respectively. R0 resection patients had better median OS, compared with patients with R1 resection or not resected (65.5 months vs. 15.5 months, p = 0.01). N0 rate among the resected patients was 63.1%, and showed a longer median OS (65.5 vs. 15.2 months, p = 0.009). CONCLUSION The results of this study confirm promising oncologic results with NAT for patients with resectable PDAC. Therefore, the present trial supports the development of phase II randomized trials comparing NAT vs. upfront surgery in resectable pancreatic cancer.
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Oncological Benefits of Neoadjuvant Chemoradiation With Gemcitabine Versus Upfront Surgery in Patients With Borderline Resectable Pancreatic Cancer. Ann Surg 2018; 268:215-222. [PMID: 29462005 DOI: 10.1097/sla.0000000000002705] [Citation(s) in RCA: 460] [Impact Index Per Article: 76.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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30
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Abstract
Pancreatic cancer is an aggressive malignancy with a poor long-term survival and only mild improvement in outcomes over the past 30 years. Local failure remains a problem and radiation can help improve control. The role of radiation therapy in has been controversial and is still evolving. This article reviews the trials of pancreatic cancer and radiation in adjuvant, neoadjuvant, and unresectable lesions. The article reviews the impact and outcomes of evolving radiation technology.
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31
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Neoadjuvant Therapy for Pancreatic Cancer: Systematic Review of Postoperative Morbidity, Mortality, and Complications. Am J Clin Oncol 2017; 39:302-13. [PMID: 26950464 DOI: 10.1097/coc.0000000000000278] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The purpose of this review was to assess whether neoadjuvant chemotherapy and chemoradiotherapy (CRT) result in differential postoperative morbidity and mortality as compared with pancreatic tumor resection surgery alone. Using PRISMA guidelines and the PubMed search engine, we reviewed all prospective phase II trials of neoadjuvant chemotherapy and CRT for pancreatic cancer that examined postoperative morbidities and mortalities. A total of 30 articles were identified, collated, and analyzed. Risks of postoperative complications vary based on trial. With surgery alone, the most common postoperative complications included delayed gastric emptying (DGE) (17% to 24%), pancreatic fistula (10% to 20%), anastomotic leaks (0% to 15%), postoperative bleeding (2% to 13%), and infections/sepsis (17% to 20%). With surgery alone, the mortality was <5%. Neoadjuvant chemotherapy showed comparable fistula rates (3% to 4%), leaks (3% to 11%), infection (3% to 7%), with mortality 0% to 4% in all but 1 study. CRT for resectable/borderline resectable patients also showed comparable complication rates: DGE (6% to 15%), fistulas (2% to 3%), leaks (3% to 7%), bleeding/hemorrhage (2% to 13%), infections/sepsis (3% to 19%), with 9/13 studies showing a mortality of ≤4%. As compared with initially borderline/resectable tumors, CRT for initially unresectable tumors (despite less data) showed higher complication rates: DGE (13% to 33%), fistulas (3% to 25%), infections/sepsis (3% to 16%). However, the confounding factor of the potentially higher tumor burden as an associative agent remains. The only parameters slightly higher than historical surgery-only complication rates were leaks and bleeding/hemorrhage (13% to 20%). Mortality rates in these patients were consistently 0%, with 2 outliers. Hence, neoadjuvant chemotherapy/CRT is safe from a postoperative complication standpoint, without significant increases in complication rates compared with surgery alone. Resectable and borderline resectable patients have fewer complications as compared with unresectable patients, although data for the latter are lacking.
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32
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Itchins M, Arena J, Nahm CB, Rabindran J, Kim S, Gibbs E, Bergamin S, Chua TC, Gill AJ, Maher R, Diakos C, Wong M, Mittal A, Hruby G, Kneebone A, Pavlakis N, Samra J, Clarke S. Retrospective cohort analysis of neoadjuvant treatment and survival in resectable and borderline resectable pancreatic ductal adenocarcinoma in a high volume referral centre. Eur J Surg Oncol 2017; 43:1711-1717. [PMID: 28688722 DOI: 10.1016/j.ejso.2017.06.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 05/28/2017] [Accepted: 06/09/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) is a deadly disease. Neoadjuvant therapy (NA) with chemotherapy (NAC) and radiotherapy (RT) prior to surgery provides promise. In the absence of prospective data, well annotated clinical data from high-volume units may provide pilot data for randomised trials. METHODS Medical records from a tertiary hospital in Sydney, Australia, were analysed to identify all patients with resectable or borderline resectable PDAC. Data regarding treatment, toxicity and survival were collected. RESULTS Between January 1 2010 and April 1 2016, 220 sequential patients were treated: 87 with NA and 133 with upfront operation (UO). Forty-three NA patients (52%) and 5 UO patients (4%) were borderline resectable at diagnosis. Twenty-four borderline patients received NA RT, 22 sequential to NAC. The median overall survival (OS) in the NA group was 25.9 months (mo); 95% CI (21.1-43.0 mo) compared to 26.9 mo (19.7, 32.7) in the UO; HR 0.89; log-ranked p-value = 0.58. Sixty-nine NA patients (79%) were resected, mOS was 29.2 mo (22.27, not reached (NR)). Twenty-two NA (31%) versus 22 UO (17%) were node negative at operation (N0). In those managed with NAC/RT the mOS was 29.0 mo (17.3, NR). There were no post-operative deaths with NA within 90-days and three in the UO arm. DISCUSSION This is a hypothesis generating retrospective review of a selected real-world population in a high-throughput unit. Treatment with NA was well tolerated. The long observed survival in this group may be explained by lymph node sterilisation by NA, and the achievement of R0 resection in a greater proportion of patients.
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Affiliation(s)
- M Itchins
- Department of Oncology, Royal North Shore Hospital, Sydney, NSW, Australia; Sydney Medical School (Northern), The University of Sydney, Australia.
| | - J Arena
- Department of Oncology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - C B Nahm
- Upper GI Surgical Unit, Department of Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, NSW, Australia; Sydney Medical School (Northern), The University of Sydney, Australia
| | - J Rabindran
- Upper GI Surgical Unit, Department of Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, NSW, Australia; Sydney Medical School (Northern), The University of Sydney, Australia
| | - S Kim
- Upper GI Surgical Unit, Department of Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, NSW, Australia
| | - E Gibbs
- National Health and Medical Research Council Clinical Trial Centre (NHMRC CTC), The University of Sydney, Australia
| | - S Bergamin
- Department of Oncology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - T C Chua
- Upper GI Surgical Unit, Department of Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, NSW, Australia
| | - A J Gill
- Sydney Medical School (Northern), The University of Sydney, Australia; Cancer Diagnosis and Pathology, Kolling Institute, Royal North Shore Hospital, Sydney, Australia
| | - R Maher
- Department of Radiology, Royal North Shore Hospital, Australia
| | - C Diakos
- Department of Oncology, Royal North Shore Hospital, Sydney, NSW, Australia; Sydney Medical School (Northern), The University of Sydney, Australia; Northern Cancer Institute, Sydney, NSW, Australia
| | - M Wong
- Department of Medical Oncology, Gosford Hospital, New South Wales, Australia
| | - A Mittal
- Upper GI Surgical Unit, Department of Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, NSW, Australia; Sydney Medical School (Northern), The University of Sydney, Australia
| | - G Hruby
- Department of Oncology, Royal North Shore Hospital, Sydney, NSW, Australia; Sydney Medical School (Northern), The University of Sydney, Australia
| | - A Kneebone
- Department of Oncology, Royal North Shore Hospital, Sydney, NSW, Australia; Sydney Medical School (Northern), The University of Sydney, Australia
| | - N Pavlakis
- Department of Oncology, Royal North Shore Hospital, Sydney, NSW, Australia; Sydney Medical School (Northern), The University of Sydney, Australia; Northern Cancer Institute, Sydney, NSW, Australia
| | - J Samra
- Upper GI Surgical Unit, Department of Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, NSW, Australia; Sydney Medical School (Northern), The University of Sydney, Australia
| | - S Clarke
- Department of Oncology, Royal North Shore Hospital, Sydney, NSW, Australia; Sydney Medical School (Northern), The University of Sydney, Australia; Northern Cancer Institute, Sydney, NSW, Australia
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Okano K, Suto H, Oshima M, Maeda E, Yamamoto N, Kakinoki K, Kamada H, Masaki T, Takahashi S, Shibata T, Suzuki Y. A Prospective Phase II Trial of Neoadjuvant S-1 with Concurrent Hypofractionated Radiotherapy in Patients with Resectable and Borderline Resectable Pancreatic Ductal Adenocarcinoma. Ann Surg Oncol 2017; 24:2777-2784. [PMID: 28608121 DOI: 10.1245/s10434-017-5921-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND The ideal neoadjuvant treatment protocol for patients with pancreatic cancer (PDAC) remains unclear. We evaluated the efficacy and safety of neoadjuvant hypofractionated chemoradiotherapy with S-1 for patients with resectable (R) and borderline resectable (BR) PDAC. METHODS Eligibility criteria included patients with R and BR PDAC, performance status 0-1, and age 20-85 years. Hypofractionated external-beam radiotherapy (30 Gy in 10 fractions) with concurrent S-1 (60 mg/m2) was delivered 5 days/week for 2 weeks prior to pancreatectomy. RESULTS Fifty-seven patients were enrolled in this study, including 33 R and 24 BR [19 BR tumors with portal vein contact (BR-PV) and 5 BR tumors with arterial contact (BR-A)]. The total rates of protocol treatment completion and resection were 91% (50/57) and 96% (55/57), respectively. Seven patients failed to complete S-1 due to cholangitis (n = 5) or neutropenia (n = 2). The most common grade 3 toxicities [Common Terminology Criteria for Adverse Events (CTCAE) version 4.0] were anorexia (7%), nausea (5%), neutropenia (4%), and leukopenia (4%). No patient experienced grade 4 toxicity. Pathologically negative margins (R0) were achieved in 54 of 55 patients (98%) who underwent pancreatectomy. Pathological response was classified as Evans grade I in 8 patients (15%), IIa in 31 patients (56%), IIb in 14 patients (25%), III in 1 patient (2%), and IV in 1 patient (2%), and operative morbidity (Clavien-Dindo grade IIIb or less) was observed in 4 patients (8%). The 1- and 2-year overall survival (OS) rates were 91 and 83% in R patients, respectively, and 77 and 58% in BR patients, respectively (p = 0.03). CONCLUSION Neoadjuvant S-1 with concurrent hypofractionated radiotherapy is tolerable and appears promising for patients with R and BR PDAC.
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Affiliation(s)
- Keiichi Okano
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan.
| | - Hironobu Suto
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
| | - Minoru Oshima
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
| | - Eri Maeda
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
| | - Naoki Yamamoto
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
| | - Keitaro Kakinoki
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
| | - Hideki Kamada
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
| | - Tsutomu Masaki
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
| | - Shigeo Takahashi
- Department of Radiation Oncology, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
| | - Toru Shibata
- Department of Radiation Oncology, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
| | - Yasuyuki Suzuki
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
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Zhan HX, Xu JW, Wu D, Wu ZY, Wang L, Hu SY, Zhang GY. Neoadjuvant therapy in pancreatic cancer: a systematic review and meta-analysis of prospective studies. Cancer Med 2017; 6:1201-1219. [PMID: 28544758 PMCID: PMC5463082 DOI: 10.1002/cam4.1071] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 03/12/2017] [Accepted: 03/13/2017] [Indexed: 12/13/2022] Open
Abstract
There is a strong rationale and many theoretical advantages for neoadjuvant therapy in pancreatic cancer (PC). However, study results have varied significantly. In this study, a systematic review and meta‐analysis of prospective studies were performed in order to evaluate safety and effectiveness of neoadjuvant therapy in PC. Thirty‐nine studies were selected (n = 1458 patients), with 14 studies focusing on patients with resectable disease (group 1), and 19 studies focusing on patients with borderline resectable and locally advanced disease (group 2). Neoadjuvant chemotherapy was administered in 97.4% of the studies, in which 76.9% was given radiotherapy and 74.4% administered with chemoradiation. The complete and partial response rate was 3.8% and 20.9%. The incidence of grade 3/4 toxicity was 11.3%. The overall resection rate after neoadjuvant therapy was 57.7% (group 1: 73.0%, group 2: 40.2%). The R0 resection rate was 84.2% (group 1: 88.2%, group 2: 79.4%). The overall survival for all patients was 16.79 months (resected 24.24, unresected 9.81; group 1: 17.76, group 2: 16.20). Our results demonstrate that neoadjuvant therapy has not been proven to be beneficial and should be considered with caution in patients with resectable PC. Patients with borderline resectable or locally advanced disease may benefit from neoadjuvant therapy, but further research is needed.
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Affiliation(s)
- Han-Xiang Zhan
- Department of General Surgery, Qilu hospital, Shandong University, Jinan, Shandong Province, 250012, China
| | - Jian-Wei Xu
- Department of General Surgery, Qilu hospital, Shandong University, Jinan, Shandong Province, 250012, China
| | - Dong Wu
- Department of General Surgery, Qilu hospital, Shandong University, Jinan, Shandong Province, 250012, China
| | - Zhi-Yang Wu
- Department of General Surgery, Qilu hospital, Shandong University, Jinan, Shandong Province, 250012, China
| | - Lei Wang
- Department of General Surgery, Qilu hospital, Shandong University, Jinan, Shandong Province, 250012, China
| | - San-Yuan Hu
- Department of General Surgery, Qilu hospital, Shandong University, Jinan, Shandong Province, 250012, China
| | - Guang-Yong Zhang
- Department of General Surgery, Qilu hospital, Shandong University, Jinan, Shandong Province, 250012, China
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The Role of Radiation Therapy for Pancreatic Cancer in the Adjuvant and Neoadjuvant Settings. Surg Oncol Clin N Am 2017; 26:431-453. [PMID: 28576181 DOI: 10.1016/j.soc.2017.01.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Pancreatic cancer is the third leading cause of cancer-related death in the United States. Although surgery remains the only curative treatment, chemotherapy and radiation therapy are frequently used. In the adjuvant setting, radiation is usually delivered with chemotherapy to eradicate residual microscopic or macroscopic disease in the resection bed. Neoadjuvant radiation therapy has become more frequently utilized. This article reviews the historical and modern literature regarding radiation therapy in the neoadjuvant and adjuvant settings, focusing on the evolution of radiation therapy techniques and clinical trials in an attempt to identify patients best suited to receiving radiation therapy.
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Jones WE, Suh WW, Abdel-Wahab M, Abrams RA, Azad N, Das P, Dragovic J, Goodman KA, Jabbour SK, Konski AA, Koong AC, Kumar R, Lee P, Pawlik TM, Small W, Herman JM. ACR Appropriateness Criteria® Resectable Pancreatic Cancer. Am J Clin Oncol 2017; 40:109-117. [PMID: 28230650 PMCID: PMC10865430 DOI: 10.1097/coc.0000000000000370] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Management of resectable pancreatic adenocarcinoma continues to present a challenge due to a paucity of high-quality randomized studies. Administration of adjuvant chemotherapy is widely accepted due to the high risk of systemic spread associated with pancreatic adenocarcinoma, but the role of radiation therapy is less clear. This paper reviews literature associated with resectable pancreatic cancer to include prognostic factors to aid in the selection of patients appropriate for adjuvant therapies. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - William E. Jones
- University of Texas Health Science Center at San Antonio, San Antonio
| | | | | | - Ross A. Abrams
- Stritch School of Medicine Loyola University Chicago, Maywood
| | - Nilofer Azad
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, American Society of Clinical Oncology
| | - Prajnan Das
- University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Karyn A. Goodman
- University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO
| | - Salma K. Jabbour
- Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ
| | - Andre A. Konski
- University of Pennsylvania, The Chester County Hospital, West Chester, PA
| | | | | | - Percy Lee
- University of California Los Angeles, Los Angeles, CA
| | - Timothy M. Pawlik
- Johns Hopkins University, Baltimore, MD, American College of Surgeons
| | - William Small
- Stritch School of Medicine Loyola University Chicago, Maywood
| | - Joseph M. Herman
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University
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Franko J, Hsu H, Thirunavukarasu P, Frankova D, Goldman C. Chemotherapy and radiation components of neoadjuvant treatment of pancreatic head adenocarcinoma: Impact on perioperative mortality and long-term survival. Eur J Surg Oncol 2017; 43:351-357. [DOI: 10.1016/j.ejso.2016.10.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 08/29/2016] [Accepted: 10/13/2016] [Indexed: 12/31/2022] Open
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Clinical benefits of neoadjuvant chemoradiotherapy for adenocarcinoma of the pancreatic head: an observational study using inverse probability of treatment weighting. J Gastroenterol 2017; 52:81-93. [PMID: 27169844 DOI: 10.1007/s00535-016-1217-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 04/17/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND The efficacy of neoadjuvant chemoradiotherapy (NACRT) and subset of pancreatic ductal adenocarcinoma (PDAC) patients who are most likely to benefit from this strategy remain elusive. The aim of this study was to investigate the effects of NACRT in patients with resectable (R) or borderline resectable (BR) adenocarcinoma of the pancreatic head. BR diseases were classified into two groups: lesions involving exclusively the portal vein system (BR-PV) and those abutting the major artery (BR-A). METHODS A total of 504 patients treated with curative intent for PDAC were analyzed (R, n = 273; BR-PV, n = 129; BR-A, n = 102). Patients who underwent upfront surgery and those who underwent NACRT followed by surgery were compared using propensity score-matched and inverse probability of treatment-weighted analyses (UMIN000019719). RESULTS No significant differences were noted in the incidences of curative resection among the three categories (R, BR-PV and BR-A). Propensity score-weighted logistic regression analysis revealed that the incidence of pathologically positive resection margins was reduced by NACRT only for BR patients. Among the propensity score-matched patients, NACRT rather than upfront surgery significantly prolonged the median survival time of BR-PV patients (28.4 vs. 20.1 months; P = 0.044) but not that of R-PDAC patients (28.6 vs. 33.7 months; P = 0.960). NACRT prolonged the median survival time of BR-A patients (18.1 vs. 10.0 months; P = 0.046), but the results remained unsatisfactory. CONCLUSIONS These findings suggest that NACRT improves R0 rates and increases the survival of patients with BR-PV adenocarcinoma of the pancreatic head but not that of patients with R-PDAC.
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Takahashi H, Akita H, Tomokuni A, Kobayashi S, Ohigashi H, Fijiwara Y, Yano M, Sakon M, Ishikawa O. Preoperative Gemcitabine-based Chemoradiation Therapy for Borderline Resectable Pancreatic Cancer. Ann Surg 2016; 264:1091-1097. [DOI: 10.1097/sla.0000000000001547] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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de Geus SWL, Eskander MF, Bliss LA, Kasumova GG, Ng SC, Callery MP, Tseng JF. Neoadjuvant therapy versus upfront surgery for resected pancreatic adenocarcinoma: A nationwide propensity score matched analysis. Surgery 2016; 161:592-601. [PMID: 28341441 DOI: 10.1016/j.surg.2016.08.040] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 08/23/2016] [Accepted: 08/30/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Neoadjuvant therapy is an emerging paradigm in pancreatic cancer care; however, its role for resectable disease remains controversial in the absence of conclusive randomized controlled trials. The purpose of the present study is to assess the impact of neoadjuvant therapy on survival in resected pancreatic cancer patients by clinical stage. METHODS A retrospective cohort study using the National Cancer Data Base from 2004 to 2012 including nonmetastatic pancreatic adenocarcinoma patients who underwent pancreatectomy and initiated chemotherapy. Propensity score matching within each stage was used to account for potential selection bias between patients undergoing neoadjuvant therapy and upfront surgery. Overall survival was compared by the Kaplan-Meier method. RESULTS In the study, 1,541 and 7,159 patients received neoadjuvant therapy followed by surgery and upfront surgery succeeded by adjuvant therapy, respectively. In clinical stage III pancreatic cancer (n = 486), neoadjuvant therapy was associated with significant survival benefit after matching (median survival 22.9 vs 17.3 months; log-rank P < .0001) compared with conventional upfront surgery followed by adjuvant therapy; however, no survival difference was found between the 2 treatment sequences in patients with clinical stage I (n = 3,149; median survival, 26.2 vs 25.7 months; P = .4418) and II (n = 5,065; median survival, 23.5 vs 23.0 months; P = .7751) disease after matching. CONCLUSION The survival impact of neoadjuvant therapy is stage-dependent. Neoadjuvant therapy does not disadvantage survival compared with conventional upfront surgery followed by adjuvant therapy in any stage, and is associated with a significant survival advantage in stage III pancreatic cancer.
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Affiliation(s)
- Susanna W L de Geus
- Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Mariam F Eskander
- Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Lindsay A Bliss
- Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Gyulnara G Kasumova
- Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sing Chau Ng
- Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Mark P Callery
- Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jennifer F Tseng
- Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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N Kalimuthu S, Serra S, Dhani N, Hafezi-Bakhtiari S, Szentgyorgyi E, Vajpeyi R, Chetty R. Regression grading in neoadjuvant treated pancreatic cancer: an interobserver study. J Clin Pathol 2016; 70:237-243. [PMID: 27681847 DOI: 10.1136/jclinpath-2016-203947] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 07/11/2016] [Accepted: 07/14/2016] [Indexed: 01/30/2023]
Abstract
AIM Several regression grading systems have been proposed for neoadjuvant chemoradiation-treated pancreatic ductal adenocarcinoma (PDAC). This study aimed to examine the utility, reproducibility and level of concordance of three most frequently used grading systems. METHODS Four gastrointestinal pathologists used the College of American Pathologists (CAP), Evans, MD Anderson Cancer Centre (MDA) regression grading systems to grade 14 selected cases (7-20 slides from each case) of neoadjuvant chemoradiation-treated PDAC. A postscoring discussion with each pathologist was conducted. The results were entered into a standardised data collection form and statistical analyses were performed. RESULTS There was little concordance across the three systems. The Kendall coefficient of concordance agreement scores were: CAP: 2-poor, 2-fair; Evans: 1-fair, 1-moderate, 2-good; MDA: 1-poor, 2-moderate, 1-good. Interpretation in all three grades in the CAP grading system was a source of discrepancy. Furthermore, using fibrosis as a criterion to assess regression was contentious. In the Evans system, quantifying tumour destruction using arbitrary percentage cut-offs (ie, 9% vs 10%; 50% vs 51%, etc) was imprecise and subjective. Although the MDA system generated greatest concordance, this was due to 'oversimplification' surrounding wide, arbitrarily assigned thresholds of </> 5% of tumour. CONCLUSIONS All systems lacked precision and clarity for accurate regression grading. Presently the clinical utility and impact of histological regression grading in patient management is questionable. There is a need to re-evaluate regression grading in the pancreas and establish a reproducible, clinically relevant grading system.
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Affiliation(s)
- Sangeetha N Kalimuthu
- Laboratory Medicine Program, Department of Pathology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Stefano Serra
- Laboratory Medicine Program, Department of Pathology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Neesha Dhani
- Laboratory Medicine Program, Department of Medical Oncology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Sara Hafezi-Bakhtiari
- Laboratory Medicine Program, Department of Pathology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Eva Szentgyorgyi
- Laboratory Medicine Program, Department of Pathology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Rajkumar Vajpeyi
- Laboratory Medicine Program, Department of Pathology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Runjan Chetty
- Laboratory Medicine Program, Department of Pathology, University Health Network, University of Toronto, Toronto, Ontario, Canada
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de Geus SWL, Evans DB, Bliss LA, Eskander MF, Smith JK, Wolff RA, Miksad RA, Weinstein MC, Tseng JF. Neoadjuvant therapy versus upfront surgical strategies in resectable pancreatic cancer: A Markov decision analysis. Eur J Surg Oncol 2016; 42:1552-60. [PMID: 27570116 DOI: 10.1016/j.ejso.2016.07.016] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 07/10/2016] [Accepted: 07/21/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Neoadjuvant therapy is gaining acceptance as a valid treatment option for borderline resectable pancreatic cancer; however, its value for clearly resectable pancreatic cancer remains controversial. The aim of this study was to use a Markov decision analysis model, in the absence of adequately powered randomized trials, to compare the life expectancy (LE) and quality-adjusted life expectancy (QALE) of neoadjuvant therapy to conventional upfront surgical strategies in resectable pancreatic cancer patients. METHODS A Markov decision model was created to compare two strategies: attempted pancreatic resection followed by adjuvant chemoradiotherapy and neoadjuvant chemoradiotherapy followed by restaging with, if appropriate, attempted pancreatic resection. Data obtained through a comprehensive systematic search in PUBMED of the literature from 2000 to 2015 were used to estimate the probabilities used in the model. Deterministic and probabilistic sensitivity analyses were performed. RESULTS Of the 786 potentially eligible studies identified, 22 studies met the inclusion criteria and were used to extract the probabilities used in the model. Base case analyses of the model showed a higher LE (32.2 vs. 26.7 months) and QALE (25.5 vs. 20.8 quality-adjusted life months) for patients in the neoadjuvant therapy arm compared to upfront surgery. Probabilistic sensitivity analyses for LE and QALE revealed that neoadjuvant therapy is favorable in 59% and 60% of the cases respectively. CONCLUSION(S) Although conceptual, these data suggest that neoadjuvant therapy offers substantial benefit in LE and QALE for resectable pancreatic cancer patients. These findings highlight the value of further prospective randomized trials comparing neoadjuvant therapy to conventional upfront surgical strategies.
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Affiliation(s)
- S W L de Geus
- Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Department of Surgery, 330 Brookline Avenue, Boston, MA 02215, USA.
| | - D B Evans
- Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA.
| | - L A Bliss
- Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Department of Surgery, 330 Brookline Avenue, Boston, MA 02215, USA.
| | - M F Eskander
- Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Department of Surgery, 330 Brookline Avenue, Boston, MA 02215, USA.
| | - J K Smith
- Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Department of Surgery, 330 Brookline Avenue, Boston, MA 02215, USA.
| | - R A Wolff
- Department of Gastrointestinal Oncology, University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA.
| | - R A Miksad
- Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Department of Surgery, 330 Brookline Avenue, Boston, MA 02215, USA.
| | - M C Weinstein
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA.
| | - J F Tseng
- Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Department of Surgery, 330 Brookline Avenue, Boston, MA 02215, USA.
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Perioperative chemotherapy is associated with a survival advantage in early stage adenocarcinoma of the pancreatic head. Surgery 2016; 160:714-24. [PMID: 27422328 DOI: 10.1016/j.surg.2016.05.029] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 04/28/2016] [Accepted: 05/24/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND The value of neoadjuvant chemotherapy in the treatment of early stage pancreatic cancer is not yet clear. METHODS We evaluated patients from the National Cancer Data Base who underwent pancreaticoduodenectomy for clinical stage I and II pancreatic adenocarcinoma between 2006 and 2012. RESULTS In total, 7,881 patients were identified. Of these, 27.5% received no chemotherapy, 57.4% received adjuvant chemotherapy, 10.2% received neoadjuvant chemotherapy alone, and 4.9% received perioperative chemotherapy, both preoperative and postoperative chemotherapy. Neoadjuvant chemotherapy use (neoadjuvant chemotherapy alone and perioperative chemotherapy) increased from 12.0% in 2006 to 20.2% in 2012. Patients who received chemotherapy prior to the operation (neoadjuvant chemotherapy alone and perioperative chemotherapy) had greater rates of margin negative (80.2% vs 73.0%, P < .001) and node negative (58.2% vs 28.7%, P < .001) resections and shorter mean durations of stay (12.0 vs 11.1 days, P = .012) than those receiving either adjuvant chemotherapy or no chemotherapy at all. There were no differences in 30-day unplanned readmissions (P = .074) and 90-day mortality (P = .227). On Cox survival analysis, adjusted for clinical variables including age and comorbid disease, patients undergoing perioperative chemotherapy, adjuvant chemotherapy, and neoadjuvant chemotherapy alone demonstrated significantly improved overall survival relative to that of patients undergoing resection alone (all P < .001). Patients receiving perioperative chemotherapy demonstrated a significant overall survival advantage compared with those receiving adjuvant chemotherapy (hazard ratio 0.75; 95% confidence interval, 0.65-0.85). Neoadjuvant chemotherapy alone had a marginal overall survival benefit compared with adjuvant chemotherapy (hazard ratio 0.89; 95% confidence interval, 0.81-0.98). CONCLUSION Early stage pancreatic cancer patients who receive perioperative chemotherapy have better overall survival than those receiving no chemotherapy, adjuvant chemotherapy, or neoadjuvant chemotherapy alone. Patterns of postoperative morbidity are similar regardless of the sequence of therapy. Neoadjuvant chemotherapy should be considered for patients presenting with early stage pancreatic cancer.
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Russo S, Wasif Saif M. Neoadjuvant therapy for pancreatic cancer: an ongoing debate. Therap Adv Gastroenterol 2016; 9:429-36. [PMID: 27366211 PMCID: PMC4913343 DOI: 10.1177/1756283x16646524] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Suzanne Russo
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Khorana AA, Mangu PB, Berlin J, Engebretson A, Hong TS, Maitra A, Mohile SG, Mumber M, Schulick R, Shapiro M, Urba S, Zeh HJ, Katz MHG. Potentially Curable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol 2016; 34:2541-56. [PMID: 27247221 DOI: 10.1200/jco.2016.67.5553] [Citation(s) in RCA: 260] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To provide evidence-based recommendations to oncologists and others on potentially curative therapy for patients with localized pancreatic cancer. METHODS ASCO convened a panel of medical oncology, radiation oncology, surgical oncology, palliative care, and advocacy experts and conducted a systematic review of literature from January 2002 to June 2015. Outcomes included overall survival, disease-free survival, progression-free survival, and adverse events. RESULTS Nine randomized controlled trials met the systematic review criteria. RECOMMENDATIONS A multiphase computed tomography scan of the abdomen and pelvis or magnetic resonance imaging should be performed for all patients to assess the anatomic relationships of the primary tumor and for the presence of intra-abdominal metastases. Baseline performance status, comorbidity profile, and goals of care should be evaluated and established. Primary surgical resection is recommended for all patients who have no metastases, appropriate performance and comorbidity profiles, and no radiographic interface between primary tumor and mesenteric vasculature. Preoperative therapy is recommended for patients who meet specific characteristics. All patients with resected pancreatic cancer who did not receive preoperative therapy should be offered 6 months of adjuvant chemotherapy in the absence of contraindications. Adjuvant chemoradiation may be offered to patients who did not receive preoperative therapy with microscopically positive margins (R1) after resection and/or who had node-positive disease after completion of 4 to 6 months of systemic adjuvant chemotherapy. Patients should have a full assessment of symptoms, psychological status, and social supports and should receive palliative care early. Patients who have completed treatment and have no evidence of disease should be monitored. Additional information is available at www.asco.org/guidelines/PCPC and www.asco.org/guidelineswiki.
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Affiliation(s)
- Alok A Khorana
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Pamela B Mangu
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Jordan Berlin
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Anitra Engebretson
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Theodore S Hong
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Anirban Maitra
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Supriya G Mohile
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Matthew Mumber
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Richard Schulick
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Marc Shapiro
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Susan Urba
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Herbert J Zeh
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Matthew H G Katz
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
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Versteijne E, van Eijck CHJ, Punt CJA, Suker M, Zwinderman AH, Dohmen MAC, Groothuis KBC, Busch ORC, Besselink MGH, de Hingh IHJT, Ten Tije AJ, Patijn GA, Bonsing BA, de Vos-Geelen J, Klaase JM, Festen S, Boerma D, Erdmann JI, Molenaar IQ, van der Harst E, van der Kolk MB, Rasch CRN, van Tienhoven G. Preoperative radiochemotherapy versus immediate surgery for resectable and borderline resectable pancreatic cancer (PREOPANC trial): study protocol for a multicentre randomized controlled trial. Trials 2016; 17:127. [PMID: 26955809 PMCID: PMC4784417 DOI: 10.1186/s13063-016-1262-z] [Citation(s) in RCA: 114] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 02/26/2016] [Indexed: 12/20/2022] Open
Abstract
Background Pancreatic cancer is the fourth largest cause of cancer death in the United States and Europe with over 100,000 deaths per year in Europe alone. The overall 5-year survival ranges from 2–7 % and has hardly improved over the last two decades. Approximately 15 % of all patients have resectable disease at diagnosis, and of those, only a subgroup has a resectable tumour at surgical exploration. Data from cohort studies have suggested that outcome can be improved by preoperative radiochemotherapy, but data from well-designed randomized studies are lacking. Our PREOPANC phase III trial aims to test the hypothesis that median overall survival of patients with resectable or borderline resectable pancreatic cancer can be improved with preoperative radiochemotherapy. Methods/design The PREOPANC trial is a randomized, controlled, multicentric superiority trial, initiated by the Dutch Pancreatic Cancer Group. Patients with (borderline) resectable pancreatic cancer are randomized to A: direct explorative laparotomy or B: after negative diagnostic laparoscopy, preoperative radiochemotherapy, followed by explorative laparotomy. A hypofractionated radiation scheme of 15 fractions of 2.4 gray (Gy) is combined with a course of gemcitabine, 1,000 mg/m2/dose on days 1, 8 and 15, preceded and followed by a modified course of gemcitabine. The target volumes of radiation are delineated on a 4D CT scan, where at least 95 % of the prescribed dose of 36 Gy in 15 fractions should cover 98 % of the planning target volume. Standard adjuvant chemotherapy is administered in both treatment arms after resection (six cycles in arm A and four in arm B). In total, 244 patients will be randomized in 17 hospitals in the Netherlands. The primary endpoint is overall survival by intention to treat. Secondary endpoints are (R0) resection rate, disease-free survival, time to locoregional recurrence or distant metastases and perioperative complications. Secondary endpoints for the experimental arm are toxicity and radiologic and pathologic response. Discussion The PREOPANC trial is designed to investigate whether preoperative radiochemotherapy improves overall survival by means of increased (R0) resection rates in patients with resectable or borderline resectable pancreatic cancer. Trial registration Trial open for accrual: 3 April 2013 The Netherlands National Trial Register – NTR3709 (8 November 2012) EU Clinical Trials Register – 2012-003181-40 (11 December 2012)
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Affiliation(s)
- Eva Versteijne
- Department of Radiation Oncology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Casper H J van Eijck
- Department of Surgery, Erasmus Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Cornelis J A Punt
- Department of Medical Oncology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Mustafa Suker
- Department of Surgery, Erasmus Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Aeilko H Zwinderman
- Department of Clinical Epidemiologic Biostatics, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Miriam A C Dohmen
- Clinical Research Department, Comprehensive Cancer Organisation the Netherlands (IKNL), Postbus 1281, 6501 BG, Nijmegen, The Netherlands.
| | - Karin B C Groothuis
- Clinical Research Department, Comprehensive Cancer Organisation the Netherlands (IKNL), Postbus 1281, 6501 BG, Nijmegen, The Netherlands.
| | - Oliver R C Busch
- Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Marc G H Besselink
- Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Ignace H J T de Hingh
- Department of Surgery, Catharina Hospital, Postbus 1350, 5602 ZA, Eindhoven, The Netherlands.
| | - Albert J Ten Tije
- Department of Medical Oncology, Amphia Hospital, Postbus 90158, 4800 RK, Breda, The Netherlands.
| | - Gijs A Patijn
- Department of Surgery, Isala Clinics, Postbus 10400, 8000 GK, Zwolle, The Netherlands.
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Postbus 9600, 2300 RC, Leiden, The Netherlands.
| | - Judith de Vos-Geelen
- Department of Medical Oncology, Maastricht University Medical Center, Postbus 3035, 6202 NA, Maastricht, The Netherlands.
| | - Joost M Klaase
- Department of Surgery, Medical Spectrum Twente, Postbus 50 000, 7500 KA, Enschede, The Netherlands.
| | - Sebastiaan Festen
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Postbus 95500, 1090 HM, Amsterdam, The Netherlands.
| | - Djamila Boerma
- Department of Surgery, Sint Antonius Hospital, Postbus 2500, 3430 EM, Nieuwegein, The Netherlands.
| | - Joris I Erdmann
- Department of Surgery, University Medical Center Groningen, Postbus 30.001, 9700 RB, Groningen, The Netherlands.
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, Postbus 85500, 3508 GA, Utrecht, The Netherlands.
| | - Erwin van der Harst
- Department of Surgery, Maasstad Hospital, Maasstadweg 21, 3079 DZ, Rotterdam, The Netherlands.
| | - Marion B van der Kolk
- Department of Surgery, Radboud University Medical Center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands.
| | - Coen R N Rasch
- Department of Radiation Oncology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Geertjan van Tienhoven
- Department of Radiation Oncology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Clinical features and treatment outcome of borderline resectable pancreatic head/body cancer: a multi-institutional survey by the Japanese Society of Pancreatic Surgery. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 20:601-10. [PMID: 23494611 DOI: 10.1007/s00534-013-0595-1] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Optimal treatment types and prognosis for patients with borderline resectable pancreatic cancer (BRPC) remain unclear because of the lack of studies involving large series of patients. METHODS We retrospectively analyzed various prognostic factors for 624 BRPC (pancreatic head/body) patients treated from June 2002 to May 2007, by distributing questionnaires to member institutions of the Japanese Society of Pancreatic Surgery in 2010. BRPC was defined according to the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines (2009). RESULTS Among 624 patients, 539 (86.4 %) underwent curative-intent resection, showing an R0 resection rate of 65.9 %. The 3- and 5-year survival rates were 16.1 and 9.9 % in all patients, 22.8 and 12.5 % in the resected patients, and 4.4 and 0 % (P < 0.0001) in the unresected patients, respectively. The following factors influencing survival in all patients were selected as independent prognostic factors using multivariate analysis: major arterial involvement on imaging study; preoperative treatment; surgical resection; and postoperative chemotherapy. Among the resected cases, multivariate analysis revealed that major arterial involvement and remnant tumor status were independent prognostic factors. CONCLUSION BRPC included two distinct categories of tumors influencing survival: those with portal vein/superior mesenteric vein invasion alone and those with major arterial invasion, which was the most exacerbating factor in the analysis.
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Eskander MF, Bliss LA, Tseng JF. Pancreatic adenocarcinoma. Curr Probl Surg 2016; 53:107-54. [DOI: 10.1067/j.cpsurg.2016.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 01/04/2016] [Indexed: 12/17/2022]
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Abstract
Pancreas adenocarcinoma is an aggressive malignancy. The risk of recurrence remains high even for patients with localized disease undergoing surgical resection. Adjuvant systemic therapy has demonstrated the ability to reduce the risk of recurrence and prolong survival. Determination of optimal adjuvant treatment, systemic therapy, and/or combinations to further improve recurrence rates and overall survival are still needed. Neoadjuvant therapy represents an alternative emerging paradigm of investigation with several theoretic advantages over adjuvant therapy. This article summarizes the major adjuvant and neoadjuvant studies for pancreas adenocarcinoma and highlights key areas of ongoing investigation.
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Induction Chemotherapy Followed by Concurrent Full-dose Gemcitabine and Intensity-modulated Radiation Therapy for Borderline Resectable and Locally Advanced Pancreatic Adenocarcinoma. Am J Clin Oncol 2016; 39:1-7. [DOI: 10.1097/coc.0000000000000003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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