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Gratsianskiy D, Ross SB, Sucandy I, Christodoulou M, Pattilachan T, Harris N, Rosemurgy A. Do pre-operative endoscopic procedures, impact the surgical outcomes of robotic pancreaticoduodenectomy? J Robot Surg 2024; 18:279. [PMID: 38967695 DOI: 10.1007/s11701-024-02036-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 06/29/2024] [Indexed: 07/06/2024]
Abstract
The role and risks of pre-operative endoscopic procedures, such as endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound with fine needle aspiration (EUS/FNA), in patients undergoing robotic pancreaticoduodenectomy are not well-defined despite a broad consensus on the utility of these interventions for diagnostic and therapeutic purposes prior to major pancreatic operations. This study investigates the impact of such preoperative endoscopic interventions on perioperative outcomes in robotic pancreaticoduodenectomy. With Institutional Review Board (IRB) approval we retrospectively analyzed 772 patients who underwent robotic pancreatectomies between 2012 and 2023. Specifically, 430 of these patients underwent a robotic pancreaticoduodenectomy were prospectively evaluated: 93 (22%) patients underwent ERCP with EUS and FNA, 45 (10%) ERCP only, and 31 (7%) EUS and FNA, while 261 (61%) did not. Statistical analyses were performed using chi-square tests and Student's t-tests to compare perioperative outcomes between the two cohorts. Statistically significant differences were observed in patients who underwent a pre-operative endoscopic intervention and were more likely to have converted to an open operation (p = 0.04). The average number of harvested lymph nodes for patients who underwent preoperative endoscopic intervention was statistically significant compared to those who did not (p = 0.0001). All other perioperative variables were consistent across all cohorts. Patients who underwent endoscopic intervention before robotic pancreaticoduodenectomy were more likely to have an unplanned open operation. This study demonstrates the increased operative difficulties introduced by preoperative endoscopic interventions. Although there was no impact on overall patient outcomes, surgeons' experience can minimize the associated risks.
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Affiliation(s)
- Denis Gratsianskiy
- Foregut and HPB Division, Digestive Health Institute AdventHealth Tampa, 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
| | - Sharona B Ross
- Foregut and HPB Division, Digestive Health Institute AdventHealth Tampa, 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA.
| | - Iswanto Sucandy
- Foregut and HPB Division, Digestive Health Institute AdventHealth Tampa, 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
| | - Maria Christodoulou
- Foregut and HPB Division, Digestive Health Institute AdventHealth Tampa, 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
| | - Tara Pattilachan
- Foregut and HPB Division, Digestive Health Institute AdventHealth Tampa, 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
| | - Nabeel Harris
- Foregut and HPB Division, Digestive Health Institute AdventHealth Tampa, 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
| | - Alexander Rosemurgy
- Foregut and HPB Division, Digestive Health Institute AdventHealth Tampa, 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
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2
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Libia A, Marchese T, D’Ugo S, Piscitelli P, Castellana F, Clodoveo ML, Zupo R, Spampinato MG. Use of Vascular Shunt at the Time of Pancreatectomy with Venous Resection: A Systematic Review. Cancers (Basel) 2024; 16:2361. [PMID: 39001423 PMCID: PMC11240683 DOI: 10.3390/cancers16132361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2024] [Revised: 06/24/2024] [Accepted: 06/26/2024] [Indexed: 07/16/2024] Open
Abstract
BACKGROUND The rising diffusion of vascular resections during complex pancreatectomy for malignancy, for both oncological and technical matters, brought with it the use of vascular shunts, either temporary or definitive, to prevent bowel congestion and liver ischemia. This study aimed to systematically review the literature on the technical feasibility of vascular shunts during advanced pancreatic surgery, analyzing intraoperative and postoperative outcomes. METHODS A systematic literature search was performed on PubMed, Scopus, Web of Science, and the Cochrane Library Central, according to PRISMA guidelines. Studies published before 2006 were excluded, considering the lack of a standardized definition of locally advanced pancreatic cancer. The main outcomes evaluated were the overall complication rate and shunt patency. RESULTS Among 789 papers retrieved from the database search, only five fulfilled the inclusion criteria and were included in the review, amounting to a total of 145 patients undergoing a shunt creation at the time of pancreatectomy. Pancreatic adenocarcinoma (PDAC) was found to be the most common diagnosis and pancreaticoduodenectomy was the main surgical procedure, accounting for 88% and 83% of the overall cohort, respectively. The distal splenorenal shunt was the most performed. Overall, 44 out of 145 patients (30%) experienced postoperative complications; the long-term patency of definitive shunts was 83% (110 out of 120 patients). CONCLUSIONS An increasing number of patients with borderline resectable or locally advanced PDAC are becoming amenable to resection and shunt creation may facilitate vascular resection with clear margins, becoming a valid tool of modern pancreatic surgery.
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Affiliation(s)
- Annarita Libia
- General Surgery Unit, Vito Fazzi Hospital, 73100 Lecce, Italy
| | | | - Stefano D’Ugo
- General Surgery Unit, Vito Fazzi Hospital, 73100 Lecce, Italy
| | - Prisco Piscitelli
- Department of Biological and Environmental Sciences and Biotechnologies, University of Salento, 73100 Lecce, Italy
- Local Health Authority, ASL LE, 73100 Lecce, Italy
| | - Fabio Castellana
- Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, Piazza Giulio Cesare 11, 70100 Bari, Italy
| | - Maria Lisa Clodoveo
- Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, Piazza Giulio Cesare 11, 70100 Bari, Italy
| | - Roberta Zupo
- Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, Piazza Giulio Cesare 11, 70100 Bari, Italy
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3
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Domagała-Haduch M, Gorzelak-Magiera A, Michalecki Ł, Gisterek-Grocholska I. Radiochemotherapy in Pancreatic Cancer. Curr Oncol 2024; 31:3291-3300. [PMID: 38920733 PMCID: PMC11202861 DOI: 10.3390/curroncol31060250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 05/23/2024] [Accepted: 06/03/2024] [Indexed: 06/27/2024] Open
Abstract
Despite the advancements made in oncology in recent years, the treatment of pancreatic cancer remains a challenge. Five-year survival rates for this cancer do not exceed 10%. Among the reasons contributing to poor treatment outcomes are the oligosymptomatic course of the tumor, diagnostic difficulties due to the anatomical location of the organ, and the unique biological features of pancreatic cancer. The mainstay of treatment for resectable cancer is surgery and adjuvant chemotherapy. For unresectable and metastatic cancers, chemotherapy remains the primary method of treatment. At the same time, for about thirty years, there have been attempts to improve treatment outcomes by using radiotherapy combined with systemic treatment. Unlike chemotherapy, radiotherapy has no established place in the treatment of pancreatic cancer. This paper addresses the topic of radiotherapy in pancreatic cancer as a valuable method that can improve treatment outcomes alongside chemotherapy.
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Affiliation(s)
- Małgorzata Domagała-Haduch
- Department of Oncology and Radiotherapy, Medical University of Silesia, 40-514 Katowice, Poland; (A.G.-M.); (Ł.M.); (I.G.-G.)
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4
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Liu M, Wei AC. Advances in Surgery and (Neo) Adjuvant Therapy in the Management of Pancreatic Cancer. Hematol Oncol Clin North Am 2024; 38:629-642. [PMID: 38429197 DOI: 10.1016/j.hoc.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Abstract
A multimodality approach, which usually includes chemotherapy, surgery, and/or radiotherapy, is optimal for patients with localized pancreatic cancer. The timing and sequence of these interventions depend on anatomic resectability and the biological suitability of the tumor and the patient. Tumors with vascular involvement (ie, borderline resectable/locally advanced) require surgical reassessments after therapy and participation of surgeons familiar with advanced techniques. When indicated, venous reconstruction should be offered as standard of care because it has acceptable morbidity. Morbidity and mortality of pancreas surgery may be mitigated when surgery is performed at high-volume centers.
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Affiliation(s)
- Mengyuan Liu
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Alice C Wei
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
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5
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Barreto SG, Shrikhande SV, Sirohi B. Neoadjuvant Therapy in Borderline Resectable Pancreatic Cancer. Indian J Surg Oncol 2024; 15:249-254. [PMID: 38817993 PMCID: PMC11133292 DOI: 10.1007/s13193-021-01361-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 05/31/2021] [Indexed: 12/09/2022] Open
Abstract
In this perspective, we present our assessment of all of the known accumulated evidence on the role of neoadjuvant therapy in the management of borderline resectable pancreatic cancer highlighting the gaps in the data, the current regimens used and providing a brief insight into the way forward.
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Affiliation(s)
- Savio George Barreto
- Division of Surgery and Perioperative Medicine, Flinders Medical Centre, Bedford Park, Adelaide, South Australia Australia
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia Australia
| | - Shailesh V. Shrikhande
- GI and HPB Services, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra India
| | - Bhawna Sirohi
- Department of Medical Oncology, Apollo Proton Cancer Centre, Chennai, Tamil Nadu India
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6
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Ross SB, Popover J, Sucandy I, Christodoulou M, Pattilachan TM, Rosemurgy AS. The Oncological Stress Test of Neoadjuvant Therapy: A Systematic Review in Outcomes of Neoadjuvant Therapy Compared to Upfront Resection Approach for Borderline Resectable Pancreatic Adenocarcinoma. Am Surg 2024:31348241248703. [PMID: 38635295 DOI: 10.1177/00031348241248703] [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: 04/19/2024]
Abstract
Pancreatic adenocarcinoma, increasingly diagnosed in the United States, has a disheartening initial resection rate of 15%. Neoadjuvant therapy, particularly FOLFIRINOX and gemcitabine-based regimens, is gaining favor for its potential to improve resectability rates and achieving microscopically negative margins (R0) in borderline resectable cases, marked by intricate arterial or venous involvement. Despite surgery being the sole curative approach, actual benefit of neoadjuvant therapy remains debatable. This study scrutinizes current literature on oncological outcomes post-resection of borderline resectable pancreatic cancer. A MEDLINE/PubMed search was conducted to systematically compare oncological outcomes of patients treated with either neoadjuvant therapy with intent of curative resection or an "upfront resection" approach. A total of 1293 studies were initially screened and 30 were included (n = 1714) in this analysis. All studies included data on outcomes of patients with borderline resectable pancreatic adenocarcinoma being treated with neoadjuvant therapy (n = 1387) or a resection-first approach (n = 356). Patients treated with neoadjuvant therapy underwent resection 52% of the time, achieving negative margins of 43% (n = 601). Approximately 77% of patients who received an upfront resection underwent a successful resection, with 39% achieving negative margins. Neoadjuvant therapy remains marginally efficacious in treatment of borderline resectable pancreatic adenocarcinoma, as patients undergo an operation and successful resection less often when treated with neoadjuvant therapy. Rates of curative resection are comparable, despite neoadjuvant therapy being a primary recommendation in borderline resectable cases and employed more often than upfront resection. Upfront resection may offer improved resection rates by intention-to-treat, which can provide more patients with paths to curative resection.
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Affiliation(s)
- Sharona B Ross
- Digestive Health Institute, AdventHealth Tampa, Tampa, FL, USA
| | - Jesse Popover
- Digestive Health Institute, AdventHealth Tampa, Tampa, FL, USA
| | - Iswanto Sucandy
- Digestive Health Institute, AdventHealth Tampa, Tampa, FL, USA
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7
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Jethwa KR, Kim E, Berlin J, Anker CJ, Tchelebi L, Abood G, Hallemeier CL, Jabbour S, Kennedy T, Kumar R, Lee P, Sharma N, Small W, Williams V, Russo S. Executive Summary of the American Radium Society Appropriate Use Criteria for Neoadjuvant Therapy for Nonmetastatic Pancreatic Adenocarcinoma: Systematic Review and Guidelines. Am J Clin Oncol 2024; 47:185-199. [PMID: 38131628 DOI: 10.1097/coc.0000000000001076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
For patients with locoregionally confined pancreatic ductal adenocarcinoma (PDAC), margin-negative surgical resection is the only known curative treatment; however, the majority of patients are not operable candidates at initial diagnosis. Among patients with resectable disease who undergo surgery alone, the 5-year survival remains poor. Adjuvant therapies, including systemic therapy or chemoradiation, are utilized as they improve locoregional control and overall survival. There has been increasing interest in the use of neoadjuvant therapy to obtain early control of occult metastatic disease, allow local tumor response to facilitate margin-negative resection, and provide a test of time and biology to assist with the selection of candidates most likely to benefit from radical surgical resection. However, limited guidance exists regarding the relative effectiveness of treatment options. In this systematic review, the American Radium Society multidisciplinary gastrointestinal expert panel convened to develop Appropriate Use Criteria evaluating the evidence regarding neoadjuvant treatment for patients with PDAC, including surgery, systemic therapy, and radiotherapy, in terms of oncologic outcomes and quality of life. The evidence was assessed using the Population, Intervention, Comparator, Outcome, and Study (PICOS) design framework and "Preferred Reporting Items for Systematic Reviews and Meta-analyses" 2020 methodology. Eligible studies included phases 2 to 3 trials, meta-analyses, and retrospective analyses published between January 1, 2012 and December 30, 2022 in the Ovid Medline database. A summary of recommendations based on the available literature is outlined to guide practitioners in the management of patients with PDAC.
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Affiliation(s)
- Krishan R Jethwa
- Department of Radiation Oncology, Mayo Clinic College of Medicine, Rochester, MN
| | - Ed Kim
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Jordan Berlin
- Department of Medicine, Division of Hematology-Oncology, Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Christopher J Anker
- Department of Radiation Oncology, University of Vermont Larner College of Medicine, Burlington, VT
| | - Leila Tchelebi
- Department of Radiation Oncology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead
| | | | | | | | - Timothy Kennedy
- Department of Surgery, Rutgers Cancer Institute, New Brunswick, NJ
| | - Rachit Kumar
- Department of Radiation Oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Sibley Memorial Hospital, Washington DC
| | - Percy Lee
- Department of Radiation Oncology, City of Hope National Medical Center, Los Angeles, CA
| | - Navesh Sharma
- Department of Radiation Oncology, WellSpan Cancer Center, York, PA
| | - William Small
- Department of Radiation Oncology, Loyola University Stritch School of Medicine, Maywood, IL
| | - Vonetta Williams
- Department of Radiation Oncology, Memorial Sloan Kettering, New York, NY
| | - Suzanne Russo
- Department of Radiation Oncology, University Hospitals Cleveland, Case Western Reserve University School of Medicine, Cleveland, OH
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8
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Xuan M, Li N, Wu C. A meta-analysis on the efficacy of endoscopic ultrasonography for treatment of pancreatic cancer. Clinics (Sao Paulo) 2024; 79:100348. [PMID: 38552386 PMCID: PMC10998044 DOI: 10.1016/j.clinsp.2024.100348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 02/21/2024] [Accepted: 03/12/2024] [Indexed: 04/09/2024] Open
Abstract
OBJECTIVE This study aimed to systematically evaluate the efficacy and safety of Endoscopic Ultrasonography (EUS) for the treatment of pancreatic cancer. METHODS The PubMed, Embase, Web of Science, and Google Scholar databases were searched from the inception of the databases to June 2022. RevMan 5.3.0 software was utilized for data analysis. In total, 13 self-descriptive studies, which enrolled 382 patients, were finally included. RESULTS It was revealed that EUS for the treatment of pancreatic cancer exhibited a lower incidence of adverse reactions (Relative Risk Ration [RR = 0.23], 95 % Confidence interval [95 % CI 0.23-0.23]), a higher success rate (RR = 0.90, 95 % CI 0.90-0.90), and a low failure rate (RR = 0.06, 95 % CI 0.06-0.06). Moreover, EUS-guided Celiac Plexus Neurolysis (EUS-CPN) not only significantly relieved pancreatic cancer patients' pain (RR = 0.83, 95 % CI 0.83-0.83), but also significantly eliminated pain in some patients (RR = 0.09, 95 % CI 0.09-0.09). The effects of EUS on pancreatic cancer treatment were satisfactory, and few adverse reactions were found. CONCLUSION Owing to the restricted sample size in this meta-analysis, primarily consisting of descriptive studies, it was imperative to conduct more rigorously designed, multi-center, long-term follow-up, larger sample, and Randomized Controlled Trials (RCTs) to validate the findings.
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Affiliation(s)
- Min Xuan
- Department of Ultrasound, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, Jiangsu Province, China
| | - Na Li
- Department of Ultrasound, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, Jiangsu Province, China
| | - Chunyan Wu
- Department of Ultrasound, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, Jiangsu Province, China.
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9
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Shouman MA, Fuchs F, Walter F, Corradini S, Westphalen CB, Vornhülz M, Beyer G, Andrade D, Belka C, Niyazi M, Rogowski P. Stereotactic body radiotherapy for pancreatic cancer - A systematic review of prospective data. Clin Transl Radiat Oncol 2024; 45:100738. [PMID: 38370495 PMCID: PMC10873666 DOI: 10.1016/j.ctro.2024.100738] [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: 10/01/2023] [Revised: 01/05/2024] [Accepted: 01/26/2024] [Indexed: 02/20/2024] Open
Abstract
Purpose This systematic review aims to comprehensively summarize the current prospective evidence regarding Stereotactic Body Radiotherapy (SBRT) in various clinical contexts for pancreatic cancer including its use as neoadjuvant therapy for borderline resectable pancreatic cancer (BRPC), induction therapy for locally advanced pancreatic cancer (LAPC), salvage therapy for isolated local recurrence (ILR), adjuvant therapy after radical resection, and as a palliative treatment. Special attention is given to the application of magnetic resonance-guided radiotherapy (MRgRT). Methods Following PRISMA guidelines, a systematic review of the Medline database via PubMed was conducted focusing on prospective studies published within the past decade. Data were extracted concerning study characteristics, outcome measures, toxicity profiles, SBRT dosage and fractionation regimens, as well as additional systemic therapies. Results and conclusion 31 studies with in total 1,571 patients were included in this review encompassing 14 studies for LAPC, 9 for neoadjuvant treatment, 2 for adjuvant treatment, 2 for ILR, with an additional 4 studies evaluating MRgRT. In LAPC, SBRT demonstrates encouraging results, characterized by favorable local control rates. Several studies even report conversion to resectable disease with substantial resection rates reaching 39%. The adoption of MRgRT may provide a solution to the challenge to deliver ablative doses while minimizing severe toxicities. In BRPC, select prospective studies combining preoperative ablative-dose SBRT with modern induction systemic therapies have achieved remarkable resection rates of up to 80%. MRgRT also holds potential in this context. Adjuvant SBRT does not appear to confer relevant advantages over chemotherapy. While prospective data for SBRT in ILR and for palliative pain relief are limited, they corroborate positive findings from retrospective studies.
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Affiliation(s)
- Mohamed A Shouman
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
- Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - Frederik Fuchs
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
| | - Franziska Walter
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
| | - C Benedikt Westphalen
- Department of Medicine III and Comprehensive Cancer Center (CCC Munich LMU), University Hospital LMU, Munich, Germany
| | - Marlies Vornhülz
- Bavarian Cancer Research Center (BZKF), Munich, Germany
- Department of Internal Medicine II, LMU University Hospital, Munich, Germany
| | - Georg Beyer
- Bavarian Cancer Research Center (BZKF), Munich, Germany
- Department of Internal Medicine II, LMU University Hospital, Munich, Germany
| | - Dorian Andrade
- Department of General, Visceral, and Transplant Surgery, University Hospital LMU, Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
- Bavarian Cancer Research Center (BZKF), Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
- Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
- German Cancer Consortium (DKTK), Partner Site Tübingen, Germany
| | - Paul Rogowski
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
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10
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Szczepanski JM, Rudolf MA, Shi J. Clinical Evaluation of the Pancreatic Cancer Microenvironment: Opportunities and Challenges. Cancers (Basel) 2024; 16:794. [PMID: 38398185 PMCID: PMC10887250 DOI: 10.3390/cancers16040794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 02/10/2024] [Accepted: 02/12/2024] [Indexed: 02/25/2024] Open
Abstract
Advances in our understanding of pancreatic ductal adenocarcinoma (PDAC) and its tumor microenvironment (TME) have the potential to transform treatment for the hundreds of thousands of patients who are diagnosed each year. Whereas the clinical assessment of cancer cell genetics has grown increasingly sophisticated and personalized, current protocols to evaluate the TME have lagged, despite evidence that the TME can be heterogeneous within and between patients. Here, we outline current protocols for PDAC diagnosis and management, review novel biomarkers, and highlight potential opportunities and challenges when evaluating the PDAC TME as we prepare to translate emerging TME-directed therapies to the clinic.
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Affiliation(s)
| | | | - Jiaqi Shi
- Department of Pathology and Clinical Labs, University of Michigan, Ann Arbor, MI 48109, USA; (J.M.S.); (M.A.R.)
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11
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Rompen IF, Habib JR, Wolfgang CL, Javed AA. Anatomical and Biological Considerations to Determine Resectability in Pancreatic Cancer. Cancers (Basel) 2024; 16:489. [PMID: 38339242 PMCID: PMC10854859 DOI: 10.3390/cancers16030489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/11/2024] [Accepted: 01/19/2024] [Indexed: 02/12/2024] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) remains associated with poor outcomes with a 5-year survival of 12% across all stages of the disease. These poor outcomes are driven by a delay in diagnosis and an early propensity for systemic dissemination of the disease. Recently, aggressive surgical approaches involving complex vascular resections and reconstructions have become more common, thus allowing more locally advanced tumors to be resected. Unfortunately, however, even after the completion of surgery and systemic therapy, approximately 40% of patients experience early recurrence of disease. To determine resectability, many institutions utilize anatomical staging systems based on the presence and extent of vascular involvement of major abdominal vessels around the pancreas. However, these classification systems are based on anatomical considerations only and do not factor in the burden of systemic disease. By integrating the biological criteria, we possibly could avoid futile resections often associated with significant morbidity. Especially patients with anatomically resectable disease who have a heavy burden of radiologically undetected systemic disease most likely do not derive a survival benefit from resection. On the contrary, we could offer complex resections to those who have locally advanced or oligometastatic disease but have favorable systemic biology and are most likely to benefit from resection. This review summarizes the current literature on defining anatomical and biological resectability in patients with pancreatic cancer.
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Affiliation(s)
- Ingmar F. Rompen
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY 10016, USA
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Joseph R. Habib
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY 10016, USA
| | - Christopher L. Wolfgang
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY 10016, USA
| | - Ammar A. Javed
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY 10016, USA
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12
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Policelli R, Dammak S, Ward AD, Kassam Z, Johnson C, Ramsewak D, Syed Z, Siddiqi L, Siddique N, Kim D, Marshall H. A Visual Aid Tool for Detection of Pancreatic Tumour-Vessel Contact on Staging CT: A Retrospective Cohort Study. Can Assoc Radiol J 2023:8465371231217155. [PMID: 38124063 DOI: 10.1177/08465371231217155] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
Purpose: In pancreatic adenocarcinoma, the difficult distinction between normal and affected pancreas on CT studies may lead to discordance between the pre-surgical assessment of vessel involvement and intraoperative findings. We hypothesize that a visual aid tool could improve the performance of radiology residents when detecting vascular invasion in pancreatic adenocarcinoma patients. Methods: This study consisted of 94 pancreatic adenocarcinoma patient CTs. The visual aid compared the estimated body fat density of each patient with the densities surrounding the superior mesenteric artery and mapped them onto the CT scan. Four radiology residents annotated the locations of perceived vascular invasion on each scan with the visual aid overlaid on alternating scans. Using 3 expert radiologists as the reference standard, we quantified the area under the receiver operating characteristic curve to determine the performance of the tool. We then used sensitivity, specificity, balanced accuracy ((sensitivity + specificity)/2), and spatial metrics to determine the performance of the residents with and without the tool. Results: The mean area under the curve was 0.80. Radiology residents' sensitivity/specificity/balanced accuracy for predicting vascular invasion were 50%/85%/68% without the tool and 81%/79%/80% with it compared to expert radiologists, and 58%/85%/72% without the tool and 78%/77%/77% with it compared to the surgical pathology. The tool was not found to impact the spatial metrics calculated on the resident annotations of vascular invasion. Conclusion: The improvements provided by the visual aid were predominantly reflected by increased sensitivity and accuracy, indicating the potential of this tool as a learning aid for trainees.
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Affiliation(s)
- Robert Policelli
- Department of Medical Biophysics, Western University, London, ON, Canada
| | - Salma Dammak
- School of Biomedical Engineering, Western University, London, ON, Canada
| | - Aaron D Ward
- Department of Medical Biophysics, Western University, London, ON, Canada
- School of Biomedical Engineering, Western University, London, ON, Canada
- Department of Oncology, Western University, London, ON, Canada
| | - Zahra Kassam
- Department of Medical Imaging, Western University, London, ON, Canada
- St. Joseph's Health Care London, London, ON, Canada
| | | | - Darryl Ramsewak
- Department of Medical Imaging, Western University, London, ON, Canada
- London Health Sciences Centre, London, ON, Canada
| | - Zafir Syed
- Department of Medical Imaging, Western University, London, ON, Canada
| | - Lubna Siddiqi
- Department of Medical Imaging, Western University, London, ON, Canada
| | - Naman Siddique
- Department of Medical Imaging, Western University, London, ON, Canada
| | - Dongkeun Kim
- Department of Medical Imaging, Western University, London, ON, Canada
| | - Harry Marshall
- Department of Medical Imaging, Western University, London, ON, Canada
- St. Joseph's Health Care London, London, ON, Canada
- London Health Sciences Centre, London, ON, Canada
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Del Chiaro M, Sugawara T, Karam SD, Messersmith WA. Advances in the management of pancreatic cancer. BMJ 2023; 383:e073995. [PMID: 38164628 DOI: 10.1136/bmj-2022-073995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
Pancreatic cancer remains among the malignancies with the worst outcomes. Survival has been improving, but at a slower rate than other cancers. Multimodal treatment, including chemotherapy, surgical resection, and radiotherapy, has been under investigation for many years. Because of the anatomical characteristics of the pancreas, more emphasis on treatment selection has been placed on local extension into major vessels. Recently, the development of more effective treatment regimens has opened up new treatment strategies, but urgent research questions have also become apparent. This review outlines the current management of pancreatic cancer, and the recent advances in its treatment. The review discusses future treatment pathways aimed at integrating novel findings of translational and clinical research.
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Affiliation(s)
- Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- University of Colorado Cancer Center, University of Colorado School of Medicine, Aurora, CO, USA
| | - Toshitaka Sugawara
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Sana D Karam
- University of Colorado Cancer Center, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Wells A Messersmith
- University of Colorado Cancer Center, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Medical Oncology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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14
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Miyata Y, Yonamine N, Fujinuma I, Tsunenari T, Takihata Y, Hakoda H, Nakazawa A, Iwasaki T, Einama T, Togashi J, Tsujimoto H, Ueno H, Beck Y, Kishi Y. Impact of Preoperative Tumor Size on Prognosis of Resectable and Borderline Resectable Pancreatic Ductal Adenocarcinomas. Ann Surg Oncol 2023; 30:8621-8630. [PMID: 37658273 DOI: 10.1245/s10434-023-14219-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 08/08/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND Tumor size (TS) is a well-established prognostic factor of pancreatic ductal adenocarcinoma (PDAC). However, whether a uniform treatment strategy can be applied for all resectable PDACs (R-PDACs) and borderline resectable PDACs (BR-PDACs), regardless of TS, remains unclear. This study aimed to investigate the impact of preoperative TS on surgical outcomes of patients with R-PDACs and BR-PDACs. METHODS Chart data from three institutions were reviewed to select patients who underwent pancreatectomy for R-PDACs and BR-PDACs between January 2006 and December 2020. The patients were divided into TSsmall and TSlarge groups according to a TS cutoff value determined for each of R- and BR-PDAC using the minimum P value approach for the risk of R1 resection. RESULTS TS of 35 mm and 24 mm was the best cutoff value in R-PDAC and BR-PDAC, respectively. The R1 rate was higher in the TSlarge than TSsmall group, in both R- (n = 35, 37% versus n = 294, 19%; P = 0.011) and BR-PDAC (n = 89, 37% versus n = 27, 15%; P = 0.030). Overall survival was significantly better in the TSsmall than TSlarge group in R-PDAC (38.2 versus 12.1 months; P < 0.001), but comparable between the two groups in BR-DPAC (21.2 versus 22.7 months; P = 0.363). Multivariate analysis revealed TS > 35 mm as an independent predictor of worse survival in patients with R-PDAC. CONCLUSION Larger TS was associated with a higher R1 rate and is a worse prognostic factor in patients with R-PDAC.
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Affiliation(s)
- Yoichi Miyata
- Department of Surgery, Asahi General Hospital, Asahi, Chiba, Japan
| | - Naoto Yonamine
- Department of Surgery, National Defense Medical College Hospital, Tokorozawa, Saitama, Japan
| | - Ibuki Fujinuma
- Department of Surgery, National Defense Medical College Hospital, Tokorozawa, Saitama, Japan
| | - Takazumi Tsunenari
- Department of Surgery, National Defense Medical College Hospital, Tokorozawa, Saitama, Japan
| | - Yasuhiro Takihata
- Department of Surgery, National Defense Medical College Hospital, Tokorozawa, Saitama, Japan
| | - Hiroyuki Hakoda
- Department of Surgery, Asahi General Hospital, Asahi, Chiba, Japan
| | - Akiko Nakazawa
- Department of Surgery, National Defense Medical College Hospital, Tokorozawa, Saitama, Japan
| | - Toshimitsu Iwasaki
- Department of Surgery, National Defense Medical College Hospital, Tokorozawa, Saitama, Japan
| | - Takahiro Einama
- Department of Surgery, National Defense Medical College Hospital, Tokorozawa, Saitama, Japan
| | - Junichi Togashi
- Department of Surgery, Asahi General Hospital, Asahi, Chiba, Japan
| | - Hironori Tsujimoto
- Department of Surgery, National Defense Medical College Hospital, Tokorozawa, Saitama, Japan
| | - Hideki Ueno
- Department of Surgery, National Defense Medical College Hospital, Tokorozawa, Saitama, Japan
| | - Yoshifumi Beck
- Department of Hepatobiliary pancreatic surgery, Saitama Medical Center, Saitama, Japan
| | - Yoji Kishi
- Department of Surgery, National Defense Medical College Hospital, Tokorozawa, Saitama, Japan.
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15
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Conroy T, Pfeiffer P, Vilgrain V, Lamarca A, Seufferlein T, O'Reilly EM, Hackert T, Golan T, Prager G, Haustermans K, Vogel A, Ducreux M. Pancreatic cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. Ann Oncol 2023; 34:987-1002. [PMID: 37678671 DOI: 10.1016/j.annonc.2023.08.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 08/11/2023] [Accepted: 08/17/2023] [Indexed: 09/09/2023] Open
Affiliation(s)
- T Conroy
- Department of Medical Oncology, Institut de Cancérologie de Lorraine, Vandoeuvre-lès-Nancy; APEMAC, équipe MICS, Université de Lorraine, Nancy, France
| | - P Pfeiffer
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - V Vilgrain
- Centre de Recherche sur l'Inflammation U 1149, Université Paris Cité, Paris; Department of Radiology, Beaujon Hospital, APHP Nord, Clichy, France
| | - A Lamarca
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - T Seufferlein
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
| | - E M O'Reilly
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, USA
| | - T Hackert
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - T Golan
- Gastrointestinal Unit, Oncology Institute, Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - G Prager
- Department of Medicine I, Division of Oncology, Medical University of Vienna, Vienna, Austria
| | - K Haustermans
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - A Vogel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - M Ducreux
- Université Paris-Saclay, Gustave Roussy, Inserm Unité Dynamique des Cellules Tumorales, Villejuif, France
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16
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Pedrazzoli S. Currently Debated Topics on Surgical Treatment of Pancreatic Ductal Adenocarcinoma: A Narrative Review on Surgical Treatment of Borderline Resectable, Locally Advanced, and Synchronous or Metachronous Oligometastatic Tumor. J Clin Med 2023; 12:6461. [PMID: 37892599 PMCID: PMC10607532 DOI: 10.3390/jcm12206461] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 09/29/2023] [Accepted: 10/04/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Previously considered inoperable patients (borderline resectable, locally advanced, synchronous oligometastatic or metachronous pancreatic adenocarcinoma (PDAC)) are starting to become resectable thanks to advances in chemo/radiotherapy and the reduction in operative mortality. METHODS This narrative review presents a chosen literature selection, giving a picture of the current state of treatment of these patients. RESULTS Neoadjuvant therapy (NAT) is generally recognized as the treatment of choice before surgery. However, despite the increased efficacy, the best pathological response is still limited to 10.9-27.9% of patients. There are still limited data on the selection of possible NAT responders and how to diagnose non-responders early. Multidetector computed tomography has high sensitivity and low specificity in evaluating resectability after NAT, limiting the resection rate of resectable patients. Ca 19-9 and Positron emission tomography are giving promising results. The prediction of early recurrence after a radical resection of synchronous or metachronous metastatic PDAC, thus identifying patients with poor prognosis and saving them from a resection of little benefit, is still ongoing, although some promising data are available. CONCLUSION In conclusion, high-level evidence demonstrating the benefit of the surgical treatment of such patients is still lacking and should not be performed outside of high-volume centers with interdisciplinary teams of surgeons and oncologists.
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17
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Timmer FEF, Geboers B, Scheffer HJ, Bakker J, Ruarus AH, Dijkstra M, van der Lei S, Boon R, Nieuwenhuizen S, van den Bemd BAT, Schouten EAC, van den Tol PM, Puijk RS, de Vries JJJ, de Gruijl TD, Meijerink MR. Tissue Resistance Decrease during Irreversible Electroporation of Pancreatic Cancer as a Biomarker for the Adaptive Immune Response and Survival. J Vasc Interv Radiol 2023; 34:1777-1784.e4. [PMID: 37391072 DOI: 10.1016/j.jvir.2023.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 06/07/2023] [Accepted: 06/20/2023] [Indexed: 07/02/2023] Open
Abstract
PURPOSE To correlate irreversible electroporation (IRE) procedural resistance changes with survival outcomes and the IRE-induced systemic immune response in patients with locally advanced pancreatic cancer (LAPC). MATERIALS AND METHODS Data on IRE procedural tissue resistance (R) features and survival outcomes were collected from patients with LAPC treated within the context of 2 prospective clinical trials in a single tertiary center. Preprocedural and postprocedural peripheral blood samples were prospectively collected for immune monitoring. The change (ie, decrease) in R during the first 10 test pulses (ΔR10p) and during the total procedure (ΔRtotal) were calculated. Patients were divided in 2 groups on the basis of the median change in R (large ΔR vs small ΔR) and compared for differences in overall survival (OS) and progression-free survival and immune cell subsets. RESULTS A total of 54 patients were included; of these, 20 underwent immune monitoring. Linear regression modeling showed that the first 10 test pulses reflected the change in tissue resistance during the total procedure appropriately (P < .001; R2 = 0.91). A large change in tissue resistance significantly correlated with a better OS (P = .026) and longer time to disease progression (P = .045). Furthermore, a large change in tissue resistance was associated with CD8+ T cell activation through significant upregulation of Ki-67+ (P = .02) and PD-1+ (P = .047). Additionally, this subgroup demonstrated significantly increased expression of CD80 on conventional dendritic cells (cDC1; P = .027) and PD-L1 on immunosuppressive myeloid-derived suppressor cells (P = .039). CONCLUSIONS IRE procedural resistance changes may serve as a biomarker for survival and IRE-induced systemic CD8+ T cell and cDC1 activation.
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Affiliation(s)
- Florentine E F Timmer
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (UMC), location Vrije Universiteit, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Bart Geboers
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (UMC), location Vrije Universiteit, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands.
| | - Hester J Scheffer
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (UMC), location Vrije Universiteit, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Joyce Bakker
- Department of Medical Oncology, Amsterdam UMC, location Vrije Universiteit, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Alette H Ruarus
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (UMC), location Vrije Universiteit, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Madelon Dijkstra
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (UMC), location Vrije Universiteit, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Susan van der Lei
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (UMC), location Vrije Universiteit, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Rianne Boon
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (UMC), location Vrije Universiteit, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Sanne Nieuwenhuizen
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (UMC), location Vrije Universiteit, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Bente A T van den Bemd
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (UMC), location Vrije Universiteit, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Evelien A C Schouten
- Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | | | - Robbert S Puijk
- Cancer Center Amsterdam, Amsterdam, the Netherlands; Department of Radiology and Nuclear Medicine, Onze Lieve Vrouwen Gasthuis, Amsterdam, the Netherlands
| | - Jan J J de Vries
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (UMC), location Vrije Universiteit, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Tanja D de Gruijl
- Department of Medical Oncology, Amsterdam UMC, location Vrije Universiteit, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Martijn R Meijerink
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (UMC), location Vrije Universiteit, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
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18
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Sbeit W, Salman M, Khalaileh A, Zoabi A, Bramnik Z, Hovel D, Mahamid M, Israeli E, Katz L, Khoury R, Mubariki N, Lisotti A, Awadie H, Khoury T. The diagnostic accuracy of endoscopic ultrasound vs. contrast-enhanced computed tomography in local staging of pancreatic adenocarcinoma: a bi-national multicenter study. Eur J Gastroenterol Hepatol 2023; 35:974-979. [PMID: 37395225 DOI: 10.1097/meg.0000000000002605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
BACKGROUND Identification of pancreatic cancer (PC) local invasion is crucial to optimize patients' selection for surgery. AIMS To determine the diagnostic accuracy of contrast-enhanced computed tomography (CECT) and endoscopic ultrasound (EUS) in local staging of PC. METHODS We performed a multicenter study including all patients with PC who underwent surgery. RESULTS One hundred twelve patients were included. Surgical findings of peri-pancreatic lymph nodes (LN), vascular and adjacent organ involvement were seen in 67 (59.8%), 33 (29.5%) and 19 patients (17%), respectively. The diagnostic performance of EUS was better than CECT in peri-pancreatic LN. The sensitivity, specificity, positive predictive value (PPV) and negative predictive (NPV) of CECT vs. EUS were 28.4%, 80%, 67.9% and 42.9% vs. 70.2%, 75.6%, 81% and 63%, respectively. For vascular and adjacent organ involvement, the sensitivity, specificity, PPV and NPV were 45.5%, 93.7%, 75%, 80.4% and 31.6%, 89.2%, 37.5% and 86.5% for CECT, respectively, vs. 63.6%, 93.7%, 80.8%, 86.1% and 36.8%, 94.6%, 58.3% and 88% for EUS, respectively. Combining both CECT and EUS, the sensitivity for peri-pancreatic LN, vascular and adjacent organ involvement improved (76.1%, 78.8% and 42%), respectively. CONCLUSION EUS was superior to CECT in local staging. Combined EUS and CECT had a higher sensitivity than either alone.
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Affiliation(s)
- Wisam Sbeit
- Gastroenterology Department, Galilee Medical Center, Nahariya
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed
| | | | - Abed Khalaileh
- Department of Surgery, Hadassah Medical Center, Jerusalem
| | - Ahmad Zoabi
- Gastroenterology and Hepatology Institute, Emek Medical Center, Afula
| | - Zakhar Bramnik
- Department of Surgery, Baruch Padeh Medical Center, The Azrieli Faculty of Medicine, Bar Ilan University, Poria
| | - David Hovel
- Department of Gastroenterology, Wolfson Medical Center, Holon
| | | | - Eran Israeli
- Department of Gastroenterology, Wolfson Medical Center, Holon
| | - Lior Katz
- Gastroenterology Department, Hadassah Medical Center, Jerusalem
| | - Reem Khoury
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed
- Department of Surgery, Galilee Medical Center, Nahariya
| | - Nama Mubariki
- Gastroenterology Department, Bnai Zion Hospital, Haifa, Israel
| | - Andrea Lisotti
- Department of Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola, BO, Italy
| | - Halim Awadie
- Gastroenterology and Hepatology Institute, Emek Medical Center, Afula
| | - Tawfik Khoury
- Gastroenterology Department, Galilee Medical Center, Nahariya
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19
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Jeon HJ, Lim SY, Jeong H, Yoon SJ, Kim H, Shin SH, Heo JS, Han IW. Survival Benefit after Shifting from Upfront Surgery to Neoadjuvant Treatment in Borderline Resectable Pancreatic Cancer. Biomedicines 2023; 11:2302. [PMID: 37626798 PMCID: PMC10452854 DOI: 10.3390/biomedicines11082302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 08/11/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023] Open
Abstract
According to the 2016 National Comprehensive Cancer Network (NCCN) guidelines, patients with borderline resectable pancreatic cancer (BRPC) should receive chemotherapy as the first-line treatment. This study examined the real-world survival benefits of modifying BRPC treatment guidelines. Patients treated for BRPC at a single institution from 2013 to 2015 (pre-guideline group) and 2017 to 2019 (post-guideline group) were retrospectively reviewed. According to the treatment method used, patients were classified into upfront surgery (US), surgery after neoadjuvant treatment (NAT), and chemotherapy only (CO) groups. Overall survival (OS) was compared according to period and treatment type. Factors associated with OS were analyzed using a Cox regression model. Among the 165 patients, 63 were in the pre-guideline group and 102 patients were in the post-guideline group. The median OS was significantly improved in the post-guideline group compared to the pre-guideline group (29 vs. 13 months, p < 0.001). According to the treatment method, the median OS of the NAT group was significantly longer than that of the US and CO groups (40 vs. 16 vs. 15 months, respectively, p < 0.001). In multivariate analysis, tumor size, differentiation, NAT, and perineural invasion were significant prognostic factors. NAT is an important treatment option for BRPC and increased patient survival in the real world.
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Affiliation(s)
- Hyun Jeong Jeon
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu 41404, Republic of Korea
| | - Soo Yeun Lim
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - HyeJeong Jeong
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - So Jeong Yoon
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Hongbeom Kim
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Sang Hyun Shin
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Jin Seok Heo
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - In Woong Han
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
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20
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Comito T, Massaro M, Teriaca MA, Franzese C, Franceschini D, Navarria P, Clerici E, Di Cristina L, Bertolini A, Tomatis S, Reggiori G, Bresolin A, Bozzarelli S, Rimassa L, Bonifacio C, Carrara S, Santoro A, Zerbi A, Scorsetti M. Can STEreotactic Body Radiation Therapy (SBRT) Improve the Prognosis of Unresectable Locally Advanced Pancreatic Cancer? Long-Term Clinical Outcomes, Toxicity and Prognostic Factors on 142 Patients (STEP Study). Curr Oncol 2023; 30:7073-7088. [PMID: 37504373 PMCID: PMC10378012 DOI: 10.3390/curroncol30070513] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/17/2023] [Accepted: 07/21/2023] [Indexed: 07/29/2023] Open
Abstract
AIM The gold standard of care for pancreatic adenocarcinoma is the integrated treatment of surgery and chemotherapy (ChT), but about 50% of patients present with unresectable disease. Our study evaluated the efficacy in terms of local control, survival and safety of stereotactic body radiation therapy (SBRT) in locally advanced pancreatic cancer (LAPC). METHODS A retrospective study (STEP study) analyzed patients with LAPC treated with a dose of 45 Gy in 6 fractions. Local control (LC), distant progression free survival (DPFS), overall survival (OS) and toxicity were analyzed according to the Kaplan-Meier method. RESULTS A total of 142 patients were evaluated. Seventy-six patients (53.5%) received induction ChT before SBRT. The median follow-up was 11 months. One-, 2- and 3-year LC rate was 81.9%, 69.1% and 58.5%. Median DPFS was 6.03 months; 1- and 2-year DPFS rate was 19.9% and 4.5%. Median OS was 11.6 months and 1-, 2- and 3-year OS rates were 45.4%, 16.1%, and 9.8%. At univariate analysis, performed by the log-rank test, age < 70 years (p = 0.037), pre-SBRT ChT (p = 0.004) and post-SBRT ChT (p = 0.019) were associated with better OS. No patients experienced G3 toxicity. CONCLUSION SBRT represents an effective and safe therapeutic option in the multimodal treatment of patients with LAPC in terms of increased LC. When SBRT was sequentially integrated with ChT, the treatment proved to be promising in terms of OS as well.
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Affiliation(s)
- Tiziana Comito
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Maria Massaro
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Maria Ausilia Teriaca
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Ciro Franzese
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy
| | - Davide Franceschini
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Pierina Navarria
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Elena Clerici
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Luciana Di Cristina
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Anna Bertolini
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Stefano Tomatis
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Giacomo Reggiori
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Andrea Bresolin
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Silvia Bozzarelli
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Lorenza Rimassa
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Cristiana Bonifacio
- Department of Radiology, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Silvia Carrara
- Department of Gastroenterology, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Armando Santoro
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Alessandro Zerbi
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy
- Department of Pancreatic Surgery, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy
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21
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Sugumar K, Gendi S, Quereshy HA, Gupta S, Hue JJ, Rothermel LD, Ocuin LM, Ammori JB, Hardacre JM, Winter JM. An analysis of time to treatment in patients with pancreatic adenocarcinoma. Surgery 2023; 174:83-90. [PMID: 37105784 DOI: 10.1016/j.surg.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 02/20/2023] [Accepted: 03/20/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND Currently, no guidelines exist regarding the appropriate time from diagnosis to treatment among pancreatic adenocarcinoma patients. Herein, we aim to define the median time to treatment in pancreatic adenocarcinoma, factors associated with treatment delay, and prognostic significance. METHODS We conducted a retrospective study of pancreatic adenocarcinoma patients, stage I-IV, at a tertiary referral center (2017-2020). We subdivided time to treatment (days) into 4 components: (1) Ti: symptom onset to initial provider evaluation, (2) Tii: initial provider evaluation to diagnosis, (3) Tiii: diagnosis to specialist consultation, (4) Tiv: specialist visit to treatment. RESULTS In total, 217 patients met the inclusion criteria. The median Ti, Tii, Tiii, and Tiv were 20, 12, 4, and 14 days, respectively. The total time to treatment was 75 days. Patients with weight loss had longer Ti (β = 108.6). More frequent hospitalizations (β = 19.5) and misdiagnosis (β = 33.4) were associated with longer Tii. Patients with a history of malignancy (β = 15) or active treatment of a second disease (β = 19.4) had longer Tiii. Poor performance status (β = 6.2) or private insurance (β = 50.2) were associated with a longer Tiv. Black patients had longer Ti+ii+iii+iv (β = 100). Time to treatment was not associated with overall survival (P > .05). CONCLUSION It takes a median time of less than a month for a patient with pancreatic adenocarcinoma to start treatment, even after they visit a primary provider. The greatest opportunity to shorten the overall time to treatment is by having patients seek medical attention earlier (Ti).
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Affiliation(s)
- Kavin Sugumar
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, OH. http://www.twitter.com/KavinSugumar
| | - Steve Gendi
- School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Humzah A Quereshy
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, OH
| | - Shreya Gupta
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, OH
| | - Jonathan J Hue
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, OH
| | - Luke D Rothermel
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, OH
| | - Lee M Ocuin
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, OH
| | - John B Ammori
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, OH
| | - Jeffrey M Hardacre
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, OH
| | - Jordan M Winter
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, OH.
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22
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Campelo SN, Huang PH, Buie CR, Davalos RV. Recent Advancements in Electroporation Technologies: From Bench to Clinic. Annu Rev Biomed Eng 2023; 25:77-100. [PMID: 36854260 DOI: 10.1146/annurev-bioeng-110220-023800] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
Over the past decade, the increased adoption of electroporation-based technologies has led to an expansion of clinical research initiatives. Electroporation has been utilized in molecular biology for mammalian and bacterial transfection; for food sanitation; and in therapeutic settings to increase drug uptake, for gene therapy, and to eliminate cancerous tissues. We begin this article by discussing the biophysics required for understanding the concepts behind the cell permeation phenomenon that is electroporation. We then review nano- and microscale single-cell electroporation technologies before scaling up to emerging in vivo applications.
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Affiliation(s)
- Sabrina N Campelo
- Department of Biomedical Engineering and Mechanics, Virginia Tech-Wake Forest School of Biomedical Engineering and Sciences, Virginia Tech, Blacksburg, Virginia, USA;
| | - Po-Hsun Huang
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Cullen R Buie
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Rafael V Davalos
- Department of Biomedical Engineering and Mechanics, Virginia Tech-Wake Forest School of Biomedical Engineering and Sciences, Virginia Tech, Blacksburg, Virginia, USA;
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23
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de Scordilli M, Michelotti A, Zara D, Palmero L, Alberti M, Noto C, Totaro F, Foltran L, Guardascione M, Iacono D, Ongaro E, Fasola G, Puglisi F. Preoperative treatments in borderline resectable and locally advanced pancreatic cancer: current evidence and new perspectives. Crit Rev Oncol Hematol 2023; 186:104013. [PMID: 37116817 DOI: 10.1016/j.critrevonc.2023.104013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 04/10/2023] [Accepted: 04/24/2023] [Indexed: 04/30/2023] Open
Abstract
Surgery is the only curative treatment for non-metastatic pancreatic adenocarcinoma, but less than 20% of patients present a resectable disease at diagnosis. Treatment strategies and disease definition for borderline resectable pancreatic cancer (BRPC) and locally advanced pancreatic cancer (LAPC) vary in the different cancer centres. Preoperative chemotherapy (CT) is the standard of care for both BRPC and LAPC patients, however literature data are still controversial concerning the type, dose and duration of the different CT regimens, as well as regarding the integration of radiotherapy (RT) or chemoradiation (CRT) in the therapeutic algorithm. In this unsettled debate, we aimed at focusing on the therapeutic regimens currently in use and relative literature data, to report international trials comparing the available therapeutic options or explore the introduction of new pharmacological agents, and to analyse possible new scenarios in microenvironment evaluation before and after neoadjuvant therapies or in patients' selection at a molecular level.
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Affiliation(s)
- Marco de Scordilli
- Department of Medicine (DAME), University of Udine, 33100 Udine, Italy; Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, 33081 Aviano, Italy.
| | - Anna Michelotti
- Department of Medicine (DAME), University of Udine, 33100 Udine, Italy; Department of Oncology, ASUFC University Hospital of Udine, 33100 Udine, Italy.
| | - Diego Zara
- Department of Medicine (DAME), University of Udine, 33100 Udine, Italy; Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, 33081 Aviano, Italy.
| | - Lorenza Palmero
- Department of Medicine (DAME), University of Udine, 33100 Udine, Italy; Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, 33081 Aviano, Italy.
| | - Martina Alberti
- Department of Medicine (DAME), University of Udine, 33100 Udine, Italy; Department of Oncology, ASUFC University Hospital of Udine, 33100 Udine, Italy.
| | - Claudia Noto
- Department of Medicine (DAME), University of Udine, 33100 Udine, Italy; Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, 33081 Aviano, Italy.
| | - Fabiana Totaro
- Department of Medicine (DAME), University of Udine, 33100 Udine, Italy; Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, 33081 Aviano, Italy.
| | - Luisa Foltran
- Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, 33081 Aviano, Italy.
| | - Michela Guardascione
- Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, 33081 Aviano, Italy.
| | - Donatella Iacono
- Department of Oncology, ASUFC University Hospital of Udine, 33100 Udine, Italy.
| | - Elena Ongaro
- Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, 33081 Aviano, Italy.
| | - Gianpiero Fasola
- Department of Oncology, ASUFC University Hospital of Udine, 33100 Udine, Italy.
| | - Fabio Puglisi
- Department of Medicine (DAME), University of Udine, 33100 Udine, Italy; Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, 33081 Aviano, Italy.
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24
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Chalfant H, Bonds M, Scott K, Condacse A, Dennahy IS, Martin WT, Little C, Edil BH, McNally LR, Jain A. Innovative Imaging Techniques Used to Evaluate Borderline-Resectable Pancreatic Adenocarcinoma. J Surg Res 2023; 284:42-53. [PMID: 36535118 PMCID: PMC10131671 DOI: 10.1016/j.jss.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 09/15/2022] [Accepted: 10/11/2022] [Indexed: 12/23/2022]
Abstract
A diagnosis of pancreatic cancer carries a 5-y survival rate of less than 10%. Furthermore, the detection of pancreatic cancer occurs most often in later stages of the disease due to its location in the retroperitoneum and lack of symptoms (in most cases) until tumors become more advanced. Once diagnosed, cross-sectional imaging techniques are heavily utilized to determine the tumor stage and the potential for surgical resection. However, a major determinant of resectability is the extent of local vascular involvement of the mesenteric vessels and critical tributaries; current imaging techniques have limited capacity to accurately determine vascular involvement. Surrounding inflammation and fibrosis can be difficult to discriminate from viable tumor, making determination of the degree of vascular involvement unreliable. New innovations in fluorescence and optoacoustic imaging techniques may overcome these limitations and make determination of resectability more accurate. These imaging modalities are able to more clearly discern between viable tumor tissue and non-neoplastic inflammation or desmoplasia, allowing clinicians to more reliably characterize vascular involvement and develop individualized treatment plans for patients. This review will discuss the current imaging techniques used to diagnose pancreatic cancer, the barriers that current techniques raise to accurate staging, and novel fluorescence and optoacoustic imaging techniques that may provide more accurate clinical staging of pancreatic cancer.
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Affiliation(s)
- Hunter Chalfant
- Department of Surgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - Morgan Bonds
- Department of Surgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - Kristina Scott
- Department of Surgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - Anna Condacse
- Department of Surgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - Isabel S Dennahy
- Department of Surgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - W Taylor Martin
- Department of Surgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - Cooper Little
- Department of Surgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - Barish H Edil
- Department of Surgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - Lacey R McNally
- Department of Surgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma.
| | - Ajay Jain
- Department of Surgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma.
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25
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Springfeld C, Ferrone CR, Katz MHG, Philip PA, Hong TS, Hackert T, Büchler MW, Neoptolemos J. Neoadjuvant therapy for pancreatic cancer. Nat Rev Clin Oncol 2023; 20:318-337. [PMID: 36932224 DOI: 10.1038/s41571-023-00746-1] [Citation(s) in RCA: 71] [Impact Index Per Article: 71.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2023] [Indexed: 03/19/2023]
Abstract
Patients with localized pancreatic ductal adenocarcinoma (PDAC) are best treated with surgical resection of the primary tumour and systemic chemotherapy, which provides considerably longer overall survival (OS) durations than either modality alone. Regardless, most patients will have disease relapse owing to micrometastatic disease. Although currently a matter of some debate, considerable research interest has been focused on the role of neoadjuvant therapy for all forms of resectable PDAC. Whilst adjuvant combination chemotherapy remains the standard of care for patients with resectable PDAC, neoadjuvant chemotherapy seems to improve OS without necessarily increasing the resection rate in those with borderline-resectable disease. Furthermore, around 20% of patients with unresectable non-metastatic PDAC might undergo resection following 4-6 months of induction combination chemotherapy with or without radiotherapy, even in the absence of a clear radiological response, leading to improved OS outcomes in this group. Distinct molecular and biological responses to different types of therapies need to be better understood in order to enable the optimal sequencing of specific treatment modalities to further improve OS. In this Review, we describe current treatment strategies for the various clinical stages of PDAC and discuss developments that are likely to determine the optimal sequence of multimodality therapies by integrating the fundamental clinical and molecular features of the cancer.
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Affiliation(s)
- Christoph Springfeld
- Department of Medical Oncology, National Center for Tumour Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Philip A Philip
- Wayne State University School of Medicine, Department of Oncology, Henry Ford Cancer Institute, Detroit, MI, USA
| | - Theodore S Hong
- Research and Scientific Affairs, Gastrointestinal Service Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Thilo Hackert
- Department of General, Visceral and Thoracic Surgery, University hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - John Neoptolemos
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.
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26
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Miao Y, Cai B, Lu Z. Technical options in surgery for artery-involving pancreatic cancer: Invasion depth matters. Surg Open Sci 2023; 12:55-61. [PMID: 36936450 PMCID: PMC10020102 DOI: 10.1016/j.sopen.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/18/2023] [Accepted: 03/01/2023] [Indexed: 03/06/2023] Open
Abstract
Background The artery involvement explains the majority of primary unresectability of non-metastatic pancreatic cancer patients and both arterial resection and artery-sparing dissection techniques are utilized in curative-intent pancreatectomies for artery-involving pancreatic cancer (ai-PC) patients. Methods This narrative review summarized the history of resectability evaluation for ai-PC and attempted to interpret its current pitfalls that led to the divergence of resectability prediction and surgical exploration, with a focus on the rationale and the surgical outcomes of the sub-adventitial divestment technique. Results The circumferential involvement of artery by tumor currently defined the resectability of ai-PC but insufficient to preclude laparotomy with curative intent. The reasons behind could be: 1. The radiographic involvement of tumor to arterial circumference was not necessarily resulted in histopathological artery wall invasion; 2. the developed surgical techniques facilitated radical resection, better perioperative safety as well as oncological benefit. The feasibility of periadventitial dissection, sub-adventitial divestment and other artery-sparing techniques for ai-PC depended on the tumor invasion depth to the artery, i.e., whether the external elastic lamina (EEL) was invaded demonstrating a hallmark plane for sub-adventitial dissections. These techniques were reported to be complicated with preferable surgical outcomes comparing to arterial resection combined pancreatectomies, while the arterial resection combined pancreatectomies were considered performed in patients with more advanced disease. Conclusions Adequate preoperative imaging modalities with which to evaluate the tumor invasion depth to the artery are to be developed. Survival benefits after these techniques remain to be proven, with more and higher-level clinical evidence needed. Key message The current resectability evaluation criteria, which were based on radiographic circumferential involvement of the artery by tumor, was insufficient to preclude curative-intent pancreatectomies for artery-involving pancreatic cancer patients. With oncological benefit to be further proven, periarterial dissection and arterial resection have different but overlapping indications, and predicting the tumor invasion depth in major arteries was critical for surgical planning.
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Affiliation(s)
- Yi Miao
- Pancreas Center, First Affiliated Hospital, Nanjing Medical University, Nanjing, PR China
- Pancreas Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, PR China
- Corresponding author at: Pancreas Center, The First Affiliated Hospital Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, PR China.
| | - Baobao Cai
- Pancreas Center, First Affiliated Hospital, Nanjing Medical University, Nanjing, PR China
| | - Zipeng Lu
- Pancreas Center, First Affiliated Hospital, Nanjing Medical University, Nanjing, PR China
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27
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Martin RCG, Schoen EC, Philips P, Egger ME, McMasters KM, Scoggins CR. Impact of margin accentuation with intraoperative irreversible electroporation on local recurrence in resected pancreatic cancer. Surgery 2023; 173:581-589. [PMID: 36216618 PMCID: PMC9918678 DOI: 10.1016/j.surg.2022.07.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/08/2022] [Accepted: 07/12/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the rates of local recurrence and margin positivity in patients with borderline resectable pancreatic cancer after pancreatectomy with or without irreversible electroporation with margin accentuation. METHODS Prospective data for preoperative stages IIB (borderline resectable) and III were evaluated, with 75 patients undergoing pancreatectomy with irreversible electroporation with margin accentuation compared to 71 patients who underwent pancreatectomy alone from March 2010 to November 2020. RESULTS Both irreversible electroporation with margin accentuation and pancreatectomy-alone groups were similar for body mass index, Charleston comorbidity index, and sex. The irreversible electroporation with margin accentuation group had significantly greater preoperative stage III (irreversible electroporation 83% vs pancreatectomy alone 51%; P = .0001), with similar tumor location (head 64% vs 72%) and tumor size (median 2.9 vs 2.8). Neoadjuvant/induction chemotherapy and prior radiation therapy was similar in both groups (irreversible electroporation with margin accentuation 89% vs 72%). Surgical therapy included a greater percentage of pancreaticoduodenectomy in the pancreatectomy-alone group. Despite greater stage and greater percentage of margin positivity (irreversible electroporation with margin accentuation 27% vs 20%; P = not significant), rates of local recurrence were similar. The mean disease-free interval for local recurrence from time of diagnosis was similar (irreversible electroporation with margin accentuation 15.8 vs 16.5 pancreatectomy alone; P = not significant) and time of treatment (irreversible electroporation with margin accentuation 9.4 vs 10.5 months; P = not significant). Overall survival was improved with the irreversible electroporation with margin accentuation group, with a mean of 34.2 months versus 27.9 months in the pancreatectomy-alone group. CONCLUSION Irreversible electroporation with margin accentuation is safe and effective in stages IIB and III pancreatic adenocarcinomas that are technically resectable. Despite higher margin positivity rates, the time to local recurrence and the effects of recurrence were the same in the pancreatectomy-alone group.
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Affiliation(s)
- Robert C G Martin
- Division of Surgical Oncology, The Hiram C. Polk, Jr., MD Department of Surgery, University of Louisville School of Medicine, KY.
| | - Eric C Schoen
- Division of Surgical Oncology, The Hiram C. Polk, Jr., MD Department of Surgery, University of Louisville School of Medicine, KY
| | - Prejesh Philips
- Division of Surgical Oncology, The Hiram C. Polk, Jr., MD Department of Surgery, University of Louisville School of Medicine, KY
| | - Michael E Egger
- Division of Surgical Oncology, The Hiram C. Polk, Jr., MD Department of Surgery, University of Louisville School of Medicine, KY
| | - Kelly M McMasters
- Division of Surgical Oncology, The Hiram C. Polk, Jr., MD Department of Surgery, University of Louisville School of Medicine, KY
| | - Charles R Scoggins
- Division of Surgical Oncology, The Hiram C. Polk, Jr., MD Department of Surgery, University of Louisville School of Medicine, KY
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28
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Toesca DAS, Susko M, von Eyben R, Baclay JRM, Pollom EL, Jeffrey RB, Poullos PD, Poultsides GA, Fisher GA, Visser BC, Koong AC, Feng M, Chang DT. Validation of a Resectability Scoring System for Prediction of Pancreatic Adenocarcinoma Surgical Outcomes. Ann Surg Oncol 2023; 30:3479-3488. [PMID: 36792768 DOI: 10.1245/s10434-023-13120-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 01/02/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND The most used pancreatic cancer (PC) resectability criteria are descriptive in nature or based solely on dichotomous degree of involvement (< 180° or > 180°) of vessels, which allows for a high degree of subjectivity and inconsistency. METHODS Radiographic measurements of the circumferential degree and length of tumor contact with major peripancreatic vessels were retrospectively obtained from pre-treatment multi-detector computed tomography (MDCT) images from PC patients treated between 2001 and 2015 at two large academic institutions. Arterial and venous scores were calculated for each patient, then tested for a correlation with tumor resection and R0 resection. RESULTS The analysis included 466 patients. Arterial and venous scores were highly predictive of resection and R0 resection in both the training (n = 294) and validation (n = 172) cohorts. A recursive partitioning tree based on arterial and venous score cutoffs developed with the training cohort was able to stratify patients of the validation cohort into discrete groups with distinct resectability probabilities. A refined recursive partitioning tree composed of three resectability groups was generated, with probabilities of resection and R0 resection of respectively 94 and 73% for group A, 61 and 35% for group B, and 4 and 2% for group C. This resectability scoring system (RSS) was highly prognostic, predicting median overall survival times of 27, 18.9, and 13.5 months respectively for patients in RSS groups A, B, and C (p < 0.001). CONCLUSIONS The proposed RSS was highly predictive of resection, R0 resection, and prognosis for patients with PC when tested against an external dataset.
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Affiliation(s)
- Diego A S Toesca
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Matthew Susko
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Rie von Eyben
- Department of Radiation Oncology, Stanford Cancer Institute, 875 Blake Wilbur Drive MC5847, Stanford, CA, 94305, USA
| | - J Richelsyn M Baclay
- Department of Radiation Oncology, Stanford Cancer Institute, 875 Blake Wilbur Drive MC5847, Stanford, CA, 94305, USA
| | - Erqi L Pollom
- Department of Radiation Oncology, Stanford Cancer Institute, 875 Blake Wilbur Drive MC5847, Stanford, CA, 94305, USA
| | - R Brooke Jeffrey
- Department of Radiology, Stanford Cancer Institute, Stanford, CA, USA
| | - Peter D Poullos
- Department of Radiology, Stanford Cancer Institute, Stanford, CA, USA
| | | | - George A Fisher
- Department of Medical Oncology, Stanford Cancer Institute, Stanford, CA, USA
| | - Brendan C Visser
- Department of Surgery, Stanford Cancer Institute, Stanford, CA, USA
| | - Albert C Koong
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mary Feng
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Daniel T Chang
- Department of Radiation Oncology, Stanford Cancer Institute, 875 Blake Wilbur Drive MC5847, Stanford, CA, 94305, USA. .,Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA.
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29
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Einama T, Takihata Y, Aosasa S, Konno F, Kobayashi K, Yonamine N, Fujinuma I, Tsunenari T, Nakazawa A, Shinto E, Ueno H, Kishi Y. Prognosis of Pancreatic Cancer Based on Resectability: A Single Center Experience. Cancers (Basel) 2023; 15:cancers15041101. [PMID: 36831444 PMCID: PMC9954753 DOI: 10.3390/cancers15041101] [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: 12/07/2022] [Revised: 02/05/2023] [Accepted: 02/06/2023] [Indexed: 02/11/2023] Open
Abstract
Although conversion surgery has increasingly been performed for initially unresectable advanced pancreatic ductal adenocarcinoma (PDAC), the rate of conversion, including that for patients who do not undergo resection, remains unclear. Patients with PDAC who were treated between January 2013 and December 2018 were classified into three groups: resectable (R), borderline resectable (BR), and unresectable (UR). We analyzed patient outcomes, including the rate of surgical resection and survival, in each of these groups. In total, 211 patients (R, 118; BR, 22; UR, 81) were selected. Among them, 117 (99%), 18 (82%), and 15 (19%) patients in the R, BR, and UR groups, respectively, underwent surgical resection. R0 resection rates were 88, 78, and 67%, whereas median overall survival (OS) from treatment initiation were 31, 18, and 11 months (p < 0.0001) in the R, BR, and UR groups, respectively. In patients who underwent surgical resection, relapse-free survival (RFS) and OS were similar among the three groups (R vs. BR vs. UR; median RFS (months), 17 vs. 13 vs. 11, p = 0.249; median OS (months), 31 vs. 26 vs. 32, p = 0.742). Lymph node metastases and incomplete adjuvant chemotherapy were identified as independent prognostic factors for OS. Although the surgical resection rate was low, particularly in the BR and UR groups, the prognosis of patients who underwent surgical resection was similar irrespective of the initial resectability status.
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Affiliation(s)
- Takahiro Einama
- Department of Surgery, National Defense Medical College, Saitama 359-8513, Japan
| | - Yasuhiro Takihata
- Department of Surgery, National Defense Medical College, Saitama 359-8513, Japan
| | - Suefumi Aosasa
- Department of Surgery, National Defense Medical College, Saitama 359-8513, Japan
- Departmetn of Surgery, Shinkuki General Hospital, Sasitama 346-0021, Japan
| | - Fukumi Konno
- Department of Surgery, National Defense Medical College, Saitama 359-8513, Japan
| | - Kazuki Kobayashi
- Department of Surgery, National Defense Medical College, Saitama 359-8513, Japan
| | - Naoto Yonamine
- Department of Surgery, National Defense Medical College, Saitama 359-8513, Japan
| | - Ibuki Fujinuma
- Department of Surgery, National Defense Medical College, Saitama 359-8513, Japan
| | - Takazumi Tsunenari
- Department of Surgery, National Defense Medical College, Saitama 359-8513, Japan
| | - Akiko Nakazawa
- Department of Surgery, National Defense Medical College, Saitama 359-8513, Japan
| | - Eiji Shinto
- Department of Surgery, National Defense Medical College, Saitama 359-8513, Japan
| | - Hideki Ueno
- Department of Surgery, National Defense Medical College, Saitama 359-8513, Japan
| | - Yoji Kishi
- Department of Surgery, National Defense Medical College, Saitama 359-8513, Japan
- Correspondence: ; Tel.: +81-4-2995-1211
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30
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Lee B, Yoon YS, Kang M, Park Y, Lee E, Jo Y, Lee JS, Lee HW, Cho JY, Han HS. Validation of the Anatomical and Biological Definitions of Borderline Resectable Pancreatic Cancer According to the 2017 International Consensus for Survival and Recurrence in Patients with Pancreatic Ductal Adenocarcinoma Undergoing Upfront Surgery. Ann Surg Oncol 2023; 30:3444-3454. [PMID: 36695994 DOI: 10.1245/s10434-022-13043-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 11/14/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND The International Consensus Criteria (ICC) (2017) redefined patients with borderline resectable pancreatic ductal adenocarcinoma (BR-PDAC) according to anatomical, biological, and conditional aspects. However, these new criteria have not been validated comprehensively. The aim of this retrospective cohort study was to validate the anatomical and biological definitions of BR-PDAC for oncological outcomes in patients with resectable (R) and BR-PDAC undergoing upfront surgery. METHODS A total of 404 patients who underwent upfront surgery for R- and BR-PDAC from 2004 to 2020 were included. The patients were classified according to the ICC as follows: resectable (R) (n = 259), anatomical borderline (BR-A) (n = 43), biological borderline (BR-B) (n = 81), and anatomical and biologic borderline (BR-AB) (n = 21). RESULTS Compared with the R and BR-B groups, the BR-A and BR-AB groups had higher postoperative complication rates (16.5% and 27.2% vs 32.5% and 33.4%; P < 0.001) and significantly lower R0 resection rates (85.7% and 80.2% vs 65.1% and 61.9%; P = 0.003). In contrast, compared with the R and BR-A groups, the BR-B (32.1%) and BR-AB (57.1%) groups had higher early recurrence rates (within postoperative 6 months) (16.5% and 25.6% vs 32.1% and 57.1%; P < 0.001) and significantly lower 3-year recurrence-free survival rates (36.1% and 20.7% vs 12.1% and 7.8%; P < 0.001). CONCLUSION Anatomically defined BR-PDAC was associated with a higher risk of margin-positive resection and postoperative complication rates, while biologically defined BR-PDAC was associated with higher early recurrence rates and lower survival rates. Thus, the anatomical and biological definitions are useful in predicting the prognosis and determining the usefulness of neoadjuvant therapy.
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Affiliation(s)
- Boram Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Gyeonggi-do, Korea
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Gyeonggi-do, Korea.
| | - MeeYoung Kang
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Gyeonggi-do, Korea
| | - Yeshong Park
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Gyeonggi-do, Korea
| | - Eunhye Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Gyeonggi-do, Korea
| | - Yeongsoo Jo
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Gyeonggi-do, Korea
| | - Jun Suh Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Gyeonggi-do, Korea
| | - Hae Won Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Gyeonggi-do, Korea
| | - Jai Young Cho
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Gyeonggi-do, Korea
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Gyeonggi-do, Korea
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Yang P, Mao K, Gao Y, Wang Z, Wang J, Chen Y, Ma C, Bian Y, Shao C, Lu J. Tumor size measurements of pancreatic cancer with neoadjuvant therapy based on RECIST guidelines: is MRI as effective as CT? Cancer Imaging 2023; 23:8. [PMID: 36653861 PMCID: PMC9850516 DOI: 10.1186/s40644-023-00528-z] [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: 10/10/2022] [Accepted: 01/11/2023] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES To compare tumor size measurements using CT and MRI in pancreatic cancer (PC) patients with neoadjuvant therapy (NAT). METHODS This study included 125 histologically confirmed PC patients who underwent NAT. The tumor sizes from CT and MRI before and after NAT were compared by using Bland-Altman analyses and intraclass correlation coefficients (ICCs). Variations in tumor size estimates between MRI and CT in relationship to different factors, including NAT methods (chemotherapy, chemoradiotherapy), tumor locations (head/neck, body/tail), tumor regression grade (TRG) levels (0-2, 3), N stages (N0, N1/N2) and tumor resection margin status (R0, R1), were further analysed. The McNemar test was used to compare the efficacy of NAT evaluations based on the CT and MRI measurements according to RECIST 1.1 criteria. RESULTS There was no significant difference between the median tumor sizes from CT and MRI before and after NAT (P = 0.44 and 0.39, respectively). There was excellent agreement in tumor size between MRI and CT, with mean size differences and limits of agreement (LOAs) of 1.5 [-9.6 to 12.7] mm and 0.9 [-12.6 to 14.5] mm before NAT (ICC, 0.93) and after NAT (ICC, 0.91), respectively. For all the investigated factors, there was good or excellent correlation (ICC, 0.76 to 0.95) for tumor sizes between CT and MRI. There was no significant difference in the efficacy evaluation of NAT between CT and MRI measurements (P = 1.0). CONCLUSION MRI and CT have similar performance in assessing PC tumor size before and after NAT.
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Affiliation(s)
- Panpan Yang
- grid.73113.370000 0004 0369 1660Department of Radiology, Changhai Hospital of Shanghai, Naval Medical University, No. 168 Changhai Road, Shanghai, 200433 China
| | - Kuanzheng Mao
- grid.73113.370000 0004 0369 1660Department of Radiology, Changhai Hospital of Shanghai, Naval Medical University, No. 168 Changhai Road, Shanghai, 200433 China ,grid.267139.80000 0000 9188 055XSchool of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Yisha Gao
- grid.73113.370000 0004 0369 1660Department of Pathology, Changhai Hospital of Shanghai, Naval Medical University, Shanghai, China
| | - Zhen Wang
- grid.73113.370000 0004 0369 1660Department of Radiology, Changhai Hospital of Shanghai, Naval Medical University, No. 168 Changhai Road, Shanghai, 200433 China
| | - Jun Wang
- grid.73113.370000 0004 0369 1660Department of Radiology, Changhai Hospital of Shanghai, Naval Medical University, No. 168 Changhai Road, Shanghai, 200433 China
| | - Yufei Chen
- grid.24516.340000000123704535College of Electronic and Information Engineering, Tongji University, Shanghai, China
| | - Chao Ma
- grid.73113.370000 0004 0369 1660Department of Radiology, Changhai Hospital of Shanghai, Naval Medical University, No. 168 Changhai Road, Shanghai, 200433 China ,grid.24516.340000000123704535College of Electronic and Information Engineering, Tongji University, Shanghai, China
| | - Yun Bian
- grid.73113.370000 0004 0369 1660Department of Radiology, Changhai Hospital of Shanghai, Naval Medical University, No. 168 Changhai Road, Shanghai, 200433 China
| | - Chengwei Shao
- grid.73113.370000 0004 0369 1660Department of Radiology, Changhai Hospital of Shanghai, Naval Medical University, No. 168 Changhai Road, Shanghai, 200433 China
| | - Jianping Lu
- grid.73113.370000 0004 0369 1660Department of Radiology, Changhai Hospital of Shanghai, Naval Medical University, No. 168 Changhai Road, Shanghai, 200433 China
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Cui J, Jiao F, Li Q, Wang Z, Fu D, Liang J, Liang H, Xia T, Zhang T, Zhang Y, Dai G, Zhang Z, Wang J, Bai Y, Bai Y, Bi F, Chen D, Cao D, Chen J, Fang W, Gao Y, Guo J, Hao J, Hua H, Huang X, Liu W, Liu X, Li D, Li J, Li E, Li Z, Pan H, Shen L, Sun Y, Tao M, Wang C, Wang F, Xiong J, Zhang T, Zhang X, Zhan X, Zheng L, Ren G, Zhang T, Zhou J, Ma Q, Qin S, Hao C, Wang L. Chinese Society of Clinical Oncology (CSCO): Clinical guidelines for the diagnosis and treatment of pancreatic cancer. JOURNAL OF THE NATIONAL CANCER CENTER 2022; 2:205-215. [PMID: 39036552 PMCID: PMC11256594 DOI: 10.1016/j.jncc.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 07/30/2022] [Accepted: 08/18/2022] [Indexed: 11/25/2022] Open
Abstract
Pancreatic cancer is one of the leading causes of cancer-related mortality in both developed and developing countries. The incidence of pancreatic cancer in China accounts for about a quater of the global incidence, and the epidemiological characteristics and therapeutic strategies differ due to social, economic, cultural, environmental, and public health factors. Non-domestic guidelines do not reflect the clinicopathologic characteristics and treatment patterns of Chinese patients. Thus, in 2018, the Chinese Society of Clinical Oncology (CSCO) organized a panel of senior experts from all sub-specialties within the field of pancreatic oncology to compile the Chinese guidelines for the diagnosis and treatment of pancreatic cancer. The guidelines were made based on both the Western and Eastern clinical evidence and updated every one or two years. The experts made consensus judgments and classified evidence-based recommendations into various grades according to the regional differences, the accessibility of diagnostic and treatment resources, and health economic indexes in China. Here we present the latest version of the guidelines, which covers the diagnosis, treatment, and follow-up of pancreatic cancer. The guidelines might standardize the diagnosis and treatment of pancreatic cancer in China and will encourage oncologists to design and conduct more clinical trials about pancreatic cancer.
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Affiliation(s)
- Jiujie Cui
- Department of Medical Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Feng Jiao
- Department of Medical Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qi Li
- Department of Medical Oncology, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zheng Wang
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Deliang Fu
- Department of Pancreatic Surgery, Huashan Hospital, Pancreatic Disease Institute, Fudan University, Shanghai, China
| | - Jun Liang
- Department of Oncology, Peking University International Hospital, Beijing, China
| | - Houjie Liang
- Department of Oncology and Southwest Cancer Center, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Tingyi Xia
- Beijing Huaxia Jingfang Cancer Radiotherapy Center, Former Air Force General Hospital and PLA General Hospital, Beijing, China
| | - Tao Zhang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yang Zhang
- Department of Oncology, The Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Guanghai Dai
- Department of Oncology, Chinese PLA General Hospital, Beijing, China
| | - Zhihong Zhang
- Department of Pathology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jian Wang
- Department of Imaging, Changzheng Hospital, Naval Military Medical University, Shanghai, China
| | - Yongrui Bai
- Department of Radiation Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yuxian Bai
- Oncology Department of Internal Medicine, Harbin Medical University Cancer Hospital, Harbin, China
| | - Feng Bi
- Department of Medical Oncology, West China Hospital, Sichuan University, Chengdu, China
| | - Donghui Chen
- Department of Medical Oncology, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Dan Cao
- Department of Medical Oncology, West China Hospital, Sichuan University, Chengdu, China
| | - Jie Chen
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Weijia Fang
- Department of Medical Oncology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yong Gao
- Department of Oncology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jianwei Guo
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Jihui Hao
- Department of Pancreatic Cancer, National Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Haiqing Hua
- Department of Medical Oncology, Eastern Theater Command General Hospital, Qinhuai Medical District, Nanjing, China
| | - Xinyu Huang
- Department of General Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Wenchao Liu
- Department of Clinical Oncology, Xijing Hospital, Air Force Medical University, Xian, China
| | - Xiufeng Liu
- Department of Medical Oncology, Eastern Theater Command General Hospital, Qinhuai Medical District, Nanjing, China
| | - Da Li
- Department of Medical Oncology, Sir Run Run Shaw Hospital, Zhejiang University, School of Medicine, Hangzhou, China
| | - Ji Li
- Department of Pancreatic Surgery, Huashan Hospital, Pancreatic Disease Institute, Fudan University, Shanghai, China
| | - Enxiao Li
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Zhiwei Li
- Department of Gastrointestinal Medical Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Hongming Pan
- Department of Medical Oncology, Sir Run Run Shaw Hospital, Zhejiang University, School of Medicine, Hangzhou, China
| | - Lin Shen
- Department of Gastrointestinal Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, China
| | - Yongwei Sun
- Department of Biliary-Pancreatic Surgery, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, China
| | - Min Tao
- Department of Oncology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Chengfeng Wang
- State Key Lab of Molecular Oncology & Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fenghua Wang
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Jianping Xiong
- Department of Oncology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Taiping Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xuebin Zhang
- Department of Interventional Oncology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Xianbao Zhan
- Department of Medical Oncology, Changhai Hospital of Shanghai, Navy Medical University, Shanghai, China
| | - Leizhen Zheng
- Department of Oncology, Xin Hua Hospital Affiliated To Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Gang Ren
- Peking University Shougang Hospital, Beijing, China
| | - Tingting Zhang
- Oncology Department of Internal Medicine, Harbin Medical University Cancer Hospital, Harbin, China
| | - Jun Zhou
- Department of Gastrointestinal Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, China
| | - Qingyong Ma
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Shukui Qin
- Department of Medical Oncology, Eastern Theater Command General Hospital, Qinhuai Medical District, Nanjing, China
| | - Chunyi Hao
- Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital, Beijing, China
| | - Liwei Wang
- Department of Medical Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Mahmoudi T, Radmard AR, Salehnia A, Ahmadian A, Davarpanah AH, Kafieh R, Arabalibeik H. Differentiation between Pancreatic Ductal Adenocarcinoma and Normal Pancreatic Tissue for Treatment Response Assessment using Multi-Scale Texture Analysis of CT Images. J Biomed Phys Eng 2022; 12:655-668. [PMID: 36569560 PMCID: PMC9759639 DOI: 10.31661/jbpe.v0i0.2102-1283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 03/01/2021] [Indexed: 12/02/2022]
Abstract
Background Pancreatic ductal adenocarcinoma (PDAC) is the most prevalent type of pancreas cancer with a high mortality rate and its staging is highly dependent on the extent of involvement between the tumor and surrounding vessels, facilitating treatment response assessment in PDAC. Objective This study aims at detecting and visualizing the tumor region and the surrounding vessels in PDAC CT scan since, despite the tumors in other abdominal organs, clear detection of PDAC is highly difficult. Material and Methods This retrospective study consists of three stages: 1) a patch-based algorithm for differentiation between tumor region and healthy tissue using multi-scale texture analysis along with L1-SVM (Support Vector Machine) classifier, 2) a voting-based approach, developed on a standard logistic function, to mitigate false detections, and 3) 3D visualization of the tumor and the surrounding vessels using ITK-SNAP software. Results The results demonstrate that multi-scale texture analysis strikes a balance between recall and precision in tumor and healthy tissue differentiation with an overall accuracy of 0.78±0.12 and a sensitivity of 0.90±0.09 in PDAC. Conclusion Multi-scale texture analysis using statistical and wavelet-based features along with L1-SVM can be employed to differentiate between healthy and pancreatic tissues. Besides, 3D visualization of the tumor region and surrounding vessels can facilitate the assessment of treatment response in PDAC. However, the 3D visualization software must be further developed for integrating with clinical applications.
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Affiliation(s)
- Tahereh Mahmoudi
- PhD, Department of Medical Physics and Biomedical Engineering, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
- PhD, Research Centre of Biomedical Technology and Robotics (RCBTR), Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Reza Radmard
- MD, Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, Tehran Iran
| | - Aneseh Salehnia
- MD, Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, Tehran Iran
| | - Alireza Ahmadian
- PhD, Department of Medical Physics and Biomedical Engineering, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
- PhD, Research Centre of Biomedical Technology and Robotics (RCBTR), Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir H Davarpanah
- MD, Department of Radiology and Imaging Sciences, Emory University School of Medicine 1364 Clifton Rd NE Atlanta, Georgia 30322, USA
| | - Raheleh Kafieh
- PhD, Medical Image and Signal Processing Research Center, School of Advanced Technologies in Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hossein Arabalibeik
- PhD, Department of Medical Physics and Biomedical Engineering, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
- PhD, Research Centre of Biomedical Technology and Robotics (RCBTR), Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
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Routine neoadjuvant chemotherapy for all patients with resectable pancreatic ductal adenocarcinoma? A review of the evidence. Curr Opin Pharmacol 2022; 67:102305. [PMID: 36223686 DOI: 10.1016/j.coph.2022.102305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 09/07/2022] [Accepted: 09/12/2022] [Indexed: 01/25/2023]
Abstract
Pancreatic ductal adenocarcinoma is an aggressive malignancy that carries a poor prognosis because the majority of patients present with locally advanced or metastatic disease. However, even patients who are fortunate enough to present with resectable disease are often plagued by high recurrence rates. While adjuvant chemotherapy has been shown to decrease the risk of recurrence after surgery, post operative complications and poor performance status after surgery prevent up to 50% of patients from receiving it. Given the benefits of neoadjuvant therapy in patients with borderline resectable disease, it is understandable that neoadjuvant therapy has been steadily increasing in patients with resectable cancers as well. In this review paper, we highlight the rational and existing evidence of using neoadjuvant therapy in all patients with resectable pancreatic adenocarcinoma.
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Li Y, Fan Z, Zhang F, Yang J, Shi M, Liu S, Meng Y, Zhan H. Neoadjuvant therapy in pancreatic neuroendocrine neoplasms: A systematic review and meta-analysis. Front Oncol 2022; 12:981575. [PMID: 36505835 PMCID: PMC9731099 DOI: 10.3389/fonc.2022.981575] [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: 08/31/2022] [Accepted: 11/08/2022] [Indexed: 11/25/2022] Open
Abstract
Background and Objectives Neoadjuvant therapy plays an increasingly important role in pancreatic neuroendocrine neoplasms (pNENs), but the systematic evaluation of its efficacy is still lacking. The purpose of this study is to explore the role of neoadjuvant therapy in pNENs. Methods We systematically reviewed the literatures published online until October 1, 2021. Meta-analysis was conducted to generate proportion with 95% confidence intervals (95% CI) for tumor response, resection rate, R0 resection rate and survival time. Results Nine studies with 468 patients were involved in the systematic review. None of these patients met complete response (CR). Furthermore, 43.6% (95% CI [18.1, 69.0]) patients were expected to achieve partial response (PR), 51.3% (95% CI [27.9, 78.3]) to stable disease (SD), and 4.3% (95% CI [0.7, 7.9]) to progressive disease (PD). The estimate resection rate and R0 resection rate after neoadjuvant therapy were 68.2% (95% CI [44.5, 91.9]) and 60.2% (95% CI [53.5, 66.9]), respectively. There was no significant difference in resection rate between different chemotherapy regimens (41.67% vs 33.93%, P=0.453), as well as R0 resection rate (62.50% vs 68.30%, P=0.605). In terms of objective response rate (ORR), there was no significant difference between CAPTEM and FAS (41.67% vs 33.93%, P=0.453), while PRRT showed a higher ORR compared with chemotherapy, although there was also no statistical difference (49.06% vs 36.96%, P=0.154). Conclusion Neoadjuvant therapies could reduce the tumor size and stage of some borderline resectable or unresectable pNENs, and give some patients the chance of radical resection. However, according to the current data, the best treatment regimen for pNENs neoadjuvant therapy is still unknown.
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Affiliation(s)
- Yongzheng Li
- Division of Pancreatic Surgery, Department of General Surgery, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Zhiyao Fan
- Division of Pancreatic Surgery, Department of General Surgery, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Feifei Zhang
- The First Operating Theater, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Jian Yang
- Division of Pancreatic Surgery, Department of General Surgery, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Ming Shi
- Division of Pancreatic Surgery, Department of General Surgery, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Shujie Liu
- Division of Pancreatic Surgery, Department of General Surgery, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Yufan Meng
- Division of Pancreatic Surgery, Department of General Surgery, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Hanxiang Zhan
- Division of Pancreatic Surgery, Department of General Surgery, Qilu Hospital, Shandong University, Jinan, Shandong, China,*Correspondence: Hanxiang Zhan,
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Nikšić M, Minicozzi P, Weir HK, Zimmerman H, Schymura MJ, Rees JR, Coleman MP, Allemani C. Pancreatic cancer survival trends in the US from 2001 to 2014: a CONCORD-3 study. CANCER COMMUNICATIONS (LONDON, ENGLAND) 2022; 43:87-99. [PMID: 36353792 PMCID: PMC9859729 DOI: 10.1002/cac2.12375] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 08/01/2022] [Accepted: 10/11/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Survival from pancreatic cancer is low worldwide. In the US, the 5-year relative survival has been slightly higher for women, whites and younger patients than for their counterparts, and differences in age and stage at diagnosis [Corrections added Nov 16, 2022, after first online publication: a new affiliation is added to Maja Nikšić] may contribute to this pattern. We aimed to examine trends in survival by race, stage, age and sex for adults (15-99 years) diagnosed with pancreatic cancer in the US. METHODS This population-based study included 399,427 adults registered with pancreatic cancer in 41 US state cancer registries during 2001-2014, with follow-up to December 31, 2014. We estimated age-specific and age-standardized net survival at 1 and 5 years. RESULTS Overall, 12.3% of patients were blacks, and 84.2% were whites. About 9.5% of patients were diagnosed with localized disease, but 50.5% were diagnosed at an advanced stage; slightly more among blacks, mainly among men. No substantial changes were seen over time (2001-2003, 2004-2008, 2009-2014). In general, 1-year net survival was higher in whites than in blacks (26.1% vs. 22.1% during 2001-2003, 35.1% vs. 31.4% during 2009-2014). This difference was particularly evident among patients with localized disease (49.6% in whites vs. 44.6% in blacks during 2001-2003, 60.1% vs. 55.3% during 2009-2014). The survival gap between blacks and whites with localized disease was persistent at 5 years after diagnosis, and it widened over time (from 24.0% vs. 21.3% during 2001-2003 to 39.7% vs. 31.0% during 2009-2014). The survival gap was wider among men than among women. CONCLUSIONS Gaps in 1- and 5-year survival between blacks and whites were persistent throughout 2001-2014, especially for patients diagnosed with a localized tumor, for which surgery is currently the only treatment modality with the potential for cure.
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Affiliation(s)
- Maja Nikšić
- Cancer Survival GroupDepartment of Non‐Communicable Disease EpidemiologyLondon School of Hygiene & Tropical MedicineKeppel StreetLondonWC1E 7HTUK,Centre for Health Services StudiesUniversity of KentCanterburyCT2 7NFUK
| | - Pamela Minicozzi
- Cancer Survival GroupDepartment of Non‐Communicable Disease EpidemiologyLondon School of Hygiene & Tropical MedicineKeppel StreetLondonWC1E 7HTUK
| | - Hannah K Weir
- Division of Cancer Prevention and ControlCenters for Disease Control and PreventionAtlantaGA30333USA
| | - Heather Zimmerman
- Montana Central Tumor RegistryChronic Disease Prevention and Health Promotion BureauPO Box 202951, 1400 BroadwayHelenaMT59620‐2951USA
| | - Maria J Schymura
- Bureau of Cancer EpidemiologyNew York State Cancer RegistryNew York State Department of Health150 BroadwayAlbanyNY12204‐2719USA
| | - Judith R Rees
- New Hampshire State Cancer RegistryNorris Cotton Cancer Center, and Department of EpidemiologyGeisel School of MedicineDartmouth CollegeDartmouth‐Hitchcock Medical CenterOne Medical Center DriveLebanonNH03756USA
| | - Michel P Coleman
- Cancer Survival GroupDepartment of Non‐Communicable Disease EpidemiologyLondon School of Hygiene & Tropical MedicineKeppel StreetLondonWC1E 7HTUK,Cancer DivisionUniversity College London Hospitals NHS Foundation Trust250 Euston RoadLondonNW1 2PGUK
| | - Claudia Allemani
- Cancer Survival GroupDepartment of Non‐Communicable Disease EpidemiologyLondon School of Hygiene & Tropical MedicineKeppel StreetLondonWC1E 7HTUK
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37
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A histopathological study of artery wall involvement in pancreatic cancer surgery. Langenbecks Arch Surg 2022; 407:3501-3511. [DOI: 10.1007/s00423-022-02689-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 09/15/2022] [Indexed: 11/09/2022]
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Takahashi S, Ohno I, Ikeda M, Konishi M, Kobayashi T, Akimoto T, Kojima M, Morinaga S, Toyama H, Shimizu Y, Miyamoto A, Tomikawa M, Takakura N, Takayama W, Hirano S, Otsubo T, Nagino M, Kimura W, Sugimachi K, Uesaka K. Neoadjuvant S-1 With Concurrent Radiotherapy Followed by Surgery for Borderline Resectable Pancreatic Cancer: A Phase II Open-label Multicenter Prospective Trial (JASPAC05). Ann Surg 2022; 276:e510-e517. [PMID: 33065644 DOI: 10.1097/sla.0000000000004535] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE This study assessed whether neoadjuvant chemoradiotherapy (CRT) with S-1 increases the R0 resection rate in BRPC. SUMMARY OF BACKGROUND DATA Although a multidisciplinary approach that includes neoadjuvant treatment has been shown to be a better strategy for BRPC than upfront resection, a standard treatment for BRPC has not been established. METHODS A multicenter, single-arm, phase II study was performed. Patients who fulfilled the criteria for BRPC received S-1 (40 mg/m 2 bid) and concurrent radiotherapy (50.4 Gy in 28 fractions) before surgery. The primary endpoint was the R0 resection rate. At least 40 patients were required, with a 1-sided α = 0.05 and β = 0.05 and expected and threshold values for the primary endpoint of 30% and 10%, respectively. RESULTS Fifty-two patients were eligible, and 41 were confirmed to have definitive BRPC by a central review. CRT was completed in 50 (96%) patients and was well tolerated. The rate of grade 3/4 toxicity with CRT was 43%. The R0 resection rate was 52% among the 52 eligible patients and 63% among the 41 patients who were centrally confirmed to have BRPC. Postoperative grade III/IV adverse events according to the Clavien-Dindo classification were observed in 7.5%. Among the 41 centrally confirmed BRPC patients, the 2-year overall survival rate and median overall survival duration were 58% and 30.8 months, respectively. CONCLUSIONS S-1 and concurrent radiotherapy seem to be feasible and effective at increasing the R0 resection rate and improving survival in patients with BRPC. TRIAL REGISTRATION UMIN000009172.
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Affiliation(s)
- Shinichiro Takahashi
- Department of Hepato-biliary Pancreatic Surgery, National Cancer Center Hospital East, Kashiwa, Japan
- Clinical Research Support Office, National Cancer Center Hospital East, Kashiwa, Japan
| | - Izumi Ohno
- Department of Hepatobiliary & Pancreatic Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Masafumi Ikeda
- Department of Hepatobiliary & Pancreatic Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Masaru Konishi
- Department of Hepato-biliary Pancreatic Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Tatsushi Kobayashi
- Department of Diagnostic Radiology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Tetsuo Akimoto
- Department of Radiation Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Motohiro Kojima
- Division of Pathology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Soichiro Morinaga
- Department of Hepato-Biliary-Pancreatic Surgery, Kanagawa Cancer Center, Yokohama, Japan
| | - Hirochika Toyama
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yasuhiro Shimizu
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Atsushi Miyamoto
- Department of Hepato-Biliary-Pancreatic Surgery, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Moriaki Tomikawa
- Department of Hepato-Biliary-Pancreatic Surgery, Tochigi Cancer Center, Utsunomiya, Japan
| | | | - Wataru Takayama
- Department of Hepato-Biliary-Pancreatic Surgery, Chiba Cancer Center, Chiba, Japan
| | - Satoshi Hirano
- Gastroenterological Surgery II, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Takehito Otsubo
- Department of Gastroenterological Surgery, St. Marianna University School of Medicine Hospital, Kawasaki, Japan
| | - Masato Nagino
- Gastroenterological Surgery 1, Nagoya University Hospital, Nagoya, Japan
| | - Wataru Kimura
- Department of Surgery 1, Yamagata University Hospital, Yamagata, Japan
| | - Keishi Sugimachi
- Department of Hepato-Biliary-Pancreatic Surgery, National Hospital Organization Kyusyu Cancer Center, Fukuoka, Japan
| | - Katsuhiko Uesaka
- Department of Hepato-biliary Pancreatic Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
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Acuna-Villaorduna A, Shankar V, Wysota M, Jirgal A, Kabarriti R, Bellemare S, Goldman I, Kaubisch A, Aparo S, Goel S, Chuy J. Induction Chemotherapy With FOLFIRINOX Followed by Chemoradiation With Gemcitabine in Patients With Borderline-Resectable Pancreatic Ductal Adenocarcinoma. Cancer Control 2022; 29:10732748221134411. [PMID: 36221952 PMCID: PMC9558866 DOI: 10.1177/10732748221134411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Introduction Perioperative therapy is standard for patients with borderline-resectable
pancreatic ductal adenocarcinoma (BR-PDAC); however, an optimal neoadjuvant
regimen is lacking. We assessed the efficacy of FOLFIRINOX chemotherapy
followed by gemcitabine-based chemoradiation as preoperative therapy. Methods Patients received 4 cycles of FOLFIRINOX, followed by 6-weekly gemcitabine
with concomitant intensity-modulated radiation. The primary endpoint was the
R0 resection rate. Secondary outcomes included resection rate,
overall-response, overall survival (OS), progression-free survival (PFS),
and tolerability. The trial was terminated early due to slow accrual. A
Simon’s optimal two-stage phase II trial single arm design was used. The
primary hypothesis of treatment efficacy was tested using a multistage group
sequential inference procedure. The secondary failure time analysis
endpoints were assessed using the Kaplan-Meier procedure and the Cox
regression model. Results A total of 22 patients enrolled in the study, 18 (81.8%) completed
neoadjuvant treatment. The bias corrected R0 rate was 55.6% (90% CI: 33.3,
68.3; P value = .16) among patients that received at least
1 cycle of FOLFIRINOX and was 80% among patients that underwent surgery. The
median OS was 35.1 months. The median PFS among patients that underwent
surgery was 34 months. Conclusion An R0 resection rate of 55.6% is favorable. Neoadjuvant FOLFIRINOX followed
by concomitant Gemcitabine with radiation was well-tolerated.
NCT01897454
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Affiliation(s)
- Ana Acuna-Villaorduna
- Department of Medical Oncology,
Montefiore
Medical Center, Bronx, NY, USA,Department of Medical Oncology,
Albert
Einstein College of Medicine, Bronx,
NY, USA
| | - Viswanathan Shankar
- Department of Epidemiology &
Population Health, Albert Einstein College of
Medicine, Bronx, NY, USA
| | - Michael Wysota
- Department of Medical Oncology,
Montefiore
Medical Center, Bronx, NY, USA,Department of Medical Oncology,
Albert
Einstein College of Medicine, Bronx,
NY, USA
| | - Amanda Jirgal
- Department of Medical Oncology,
Montefiore
Medical Center, Bronx, NY, USA
| | - Rafi Kabarriti
- Department of Radiation Oncology,
Montefiore
Medical Center, Bronx, NY, USA,Department of Radiation Oncology,
Albert
Einstein College of Medicine, Bronx,
NY, USA
| | - Sarah Bellemare
- Department of Surgery,
Montefiore
Medical Center, Bronx, NY, USA,Department of Surgery,
Albert
Einstein College of Medicine, Bronx,
NY, USA
| | - Inessa Goldman
- Department of Radiology,
Montefiore
Medical Center, Bronx, NY, USA,Department of Radiology,
Albert
Einstein College of Medicine, Bronx,
NY, USA
| | - Andreas Kaubisch
- Department of Medical Oncology,
Montefiore
Medical Center, Bronx, NY, USA,Department of Medical Oncology,
Albert
Einstein College of Medicine, Bronx,
NY, USA
| | - Santiago Aparo
- Department of Medical Oncology,
Montefiore
Medical Center, Bronx, NY, USA,Department of Medical Oncology,
Albert
Einstein College of Medicine, Bronx,
NY, USA
| | - Sanjay Goel
- Department of Medical Oncology,
Montefiore
Medical Center, Bronx, NY, USA,Department of Medical Oncology,
Albert
Einstein College of Medicine, Bronx,
NY, USA,Sanjay Goel, MD, MS, Professor of Medicine,
Department of Medical Oncology, Albert Einstein College of Medicine, Montefiore
Medical Center, 1695 Eastchester Road, Bronx NY 10461, USA.
; Jennifer Chuy, MD, Assistant
Professor of Medicine, Department of Medical Oncology, Albert Einstein College
of Medicine, Montefiore Medical Center, 1695 Eastchester Road, Bronx NY 10461,
USA.
| | - Jennifer Chuy
- Department of Medical Oncology,
Montefiore
Medical Center, Bronx, NY, USA,Department of Medical Oncology,
Albert
Einstein College of Medicine, Bronx,
NY, USA,Sanjay Goel, MD, MS, Professor of Medicine,
Department of Medical Oncology, Albert Einstein College of Medicine, Montefiore
Medical Center, 1695 Eastchester Road, Bronx NY 10461, USA.
; Jennifer Chuy, MD, Assistant
Professor of Medicine, Department of Medical Oncology, Albert Einstein College
of Medicine, Montefiore Medical Center, 1695 Eastchester Road, Bronx NY 10461,
USA.
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Fromer MW, Wilson KD, Philips P, Egger ME, Scoggins CR, McMasters KM, Martin RCG. Locally advanced pancreatic cancer: a reliable contraindication to resection in the modern era? HPB (Oxford) 2022; 24:1789-1795. [PMID: 35491339 DOI: 10.1016/j.hpb.2021.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/19/2021] [Accepted: 09/06/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of this study is to present radiologically designated LAPC found to be resectable upon surgical exploration and evaluate the outcomes of such resections. METHODS Sequential LAPC patients between 2013 and 2019 were staged and underwent resection were included in the analysis of both perioperative and long-term outcomes. RESULTS Twenty-eight patients with radiologically-designated LAPC underwent surgical resection after chemotherapy with a median follow-up of 31.7 m,75% underwent pancreaticoduodenectomy. The margin positivity and local recurrence rates were 21.4% and 35.7%, respectively. When compared to the 30 BRPC controls, the LAPC group had a higher rates of an arterial resection (11vs.1; p = 0.002), but the groups were similar with regard to all other preoperative and intraoperative variables (p < 0.05). Perioperative morbidity rates were similar (25.9%vs21.4%; p = 0.53). The LAPC and BRPC groups were also equivalent with respect to median recurrence-free survival (9.0mo; 95%CI 6.3, 11.7vs.8.3mo; 95%CI 5.4, 11.2) and median overall survival (19.9mo; 95%CI 17.0, 22.7 vs. 19.9mo; 95%CI 14.8, 25.1), respectively. CONCLUSION Despite a radiologic designation of locally advanced pancreatic cancer, certain subtypes of LAPC warrant surgical exploration provided the operative surgeon is prepared for major arterial and/or venous resection. Pancreatectomy in these patients has acceptable morbidity and oncologic outcomes, similar to patients who are radiologically borderline resectable.
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Affiliation(s)
- Marc W Fromer
- Department of Surgery, Division of Surgical Oncology, School of Medicine, University of Louisville, Louisville, KY 40202, USA
| | - Khaleel D Wilson
- Department of Surgery, Division of Surgical Oncology, School of Medicine, University of Louisville, Louisville, KY 40202, USA
| | - Prejesh Philips
- Department of Surgery, Division of Surgical Oncology, School of Medicine, University of Louisville, Louisville, KY 40202, USA
| | - Michael E Egger
- Department of Surgery, Division of Surgical Oncology, School of Medicine, University of Louisville, Louisville, KY 40202, USA
| | - Charles R Scoggins
- Department of Surgery, Division of Surgical Oncology, School of Medicine, University of Louisville, Louisville, KY 40202, USA
| | - Kelly M McMasters
- Department of Surgery, Division of Surgical Oncology, School of Medicine, University of Louisville, Louisville, KY 40202, USA
| | - Robert C G Martin
- Department of Surgery, Division of Surgical Oncology, School of Medicine, University of Louisville, Louisville, KY 40202, USA.
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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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Savani M, Shroff RT. Decision-Making Regarding Perioperative Therapy in Individuals with Localized Pancreatic Adenocarcinoma. Hematol Oncol Clin North Am 2022; 36:961-978. [DOI: 10.1016/j.hoc.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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43
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Gupta V, Chaudhari V, Shrikhande SV, Bhandare MS. Does Preoperative Serum Neutrophil to Lymphocyte Ratio (NLR), Platelet to Lymphocyte Ratio (PLR), and Lymphocyte to Monocyte Ratio (LMR) Predict Prognosis Following Radical Surgery for Pancreatic Adenocarcinomas? Results of a Retrospective Study. J Gastrointest Cancer 2022; 53:641-648. [PMID: 34406625 DOI: 10.1007/s12029-021-00683-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pretherapy serum neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), and lymphocyte to monocyte ratio (LMR) have been shown to predict prognosis in patients with pancreatic ductal adenocarcinoma (PDAC). However, the published literature is conflicting; hence, we aimed to evaluate their role in predicting survival outcomes in operated patients of PDAC. METHODS A retrospective analysis was performed in all operated cases of PDAC who underwent curative resection between 2011 and 2018. The pretherapy NLR, PLR, and LMR were calculated and analyzed with respect to pathological and survival outcomes RESULTS: One hundred thirty-four operated patients were included. The median overall survival for NLR of less than 2, 2.7, and 5 was 30.8, 27.2, and 27.5 months and for NLR of more than 2, 2.7, and 5 was 22.9, 21.6, and 21.5 months, respectively, and was statistically insignificant (p-value-0.32, 0.91, 0.34, respectively). Similarly, the PLR was not significant for a cutoff of 150 (p-value-0.27), and LMR was not significant for a cutoff of 2.8 (p-value-0.13) and 4.8 (p-value-0.11). On univariate analysis age, CA 19-9 levels, perineural invasion, margin positivity, lymph node positivity, and TNM stage were found to have a significant correlation with overall survival. However, on multivariate analysis, only TNM stage was found to be significant. CONCLUSION The NLR, PLR, and LMR do not correlate with overall survival in operated patients with PDAC in this study. A combination of inflammatory markers or their dynamic testing might probably achieve prognostic significance.
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Affiliation(s)
- Vikas Gupta
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, 400012, Maharashtra, India
| | - Vikram Chaudhari
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, 400012, Maharashtra, India
| | - Shailesh V Shrikhande
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, 400012, Maharashtra, India
| | - Manish S Bhandare
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, 400012, Maharashtra, India.
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Katz MHG, Shi Q, Meyers J, Herman JM, Chuong M, Wolpin BM, Ahmad S, Marsh R, Schwartz L, Behr S, Frankel WL, Collisson E, Leenstra J, Williams TM, Vaccaro G, Venook A, Meyerhardt JA, O’Reilly EM. Efficacy of Preoperative mFOLFIRINOX vs mFOLFIRINOX Plus Hypofractionated Radiotherapy for Borderline Resectable Adenocarcinoma of the Pancreas: The A021501 Phase 2 Randomized Clinical Trial. JAMA Oncol 2022; 8:1263-1270. [PMID: 35834226 PMCID: PMC9284408 DOI: 10.1001/jamaoncol.2022.2319] [Citation(s) in RCA: 106] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/27/2022] [Indexed: 01/10/2023]
Abstract
Importance National guidelines endorse treatment with neoadjuvant therapy for borderline resectable pancreatic ductal adenocarcinoma (PDAC), but the optimal strategy remains unclear. Objective To compare treatment with neoadjuvant modified FOLFIRINOX (mFOLFIRINOX) with or without hypofractionated radiation therapy with historical data and establish standards for therapy in borderline resectable PDAC. Design, Setting, and Participants This prospective, multicenter, randomized phase 2 clinical trial conducted from February 2017 to January 2019 among member institutions of National Clinical Trials Network cooperative groups used standardized quality control measures and included 126 patients, of whom 70 (55.6%) were registered to arm 1 (systemic therapy; 54 randomized, 16 following closure of arm 2 at interim analysis) and 56 (44.4%) to arm 2 (systemic therapy and sequential hypofractionated radiotherapy; all randomized before closure). Data were analyzed by the Alliance Statistics and Data Management Center during September 2021. Interventions Arm 1: 8 treatment cycles of mFOLFIRINOX (oxaliplatin, 85 mg/m2; irinotecan, 180 mg/m2; leucovorin, 400 mg/m2; and infusional fluorouracil, 2400 mg/m2) over 46 hours, administered every 2 weeks. Arm 2: 7 treatment cycles of mFOLFIRINOX followed by stereotactic body radiotherapy (33-40 Gy in 5 fractions) or hypofractionated image-guided radiotherapy (25 Gy in 5 fractions). Patients without disease progression underwent pancreatectomy, which was followed by 4 cycles of treatment with postoperative FOLFOX6 (oxaliplatin, 85 mg/m2; leucovorin, 400 mg/m2; bolus fluorouracil, 400 mg/m2; and infusional fluorouracil, 2400 mg/m2 over 46 hours). Main Outcomes and Measures Each treatment arm's 18-month overall survival (OS) rate was compared with a historical control rate of 50%. A planned interim analysis mandated closure of either arm for which 11 or fewer of the first 30 accrued patients underwent margin-negative (R0) resection. Results Of 126 patients, 62 (49%) were women, and the median (range) age was 64 (37-83) years. Among the first 30 evaluable patients enrolled to each arm, 17 patients in arm 1 (57%) and 10 patients in arm 2 (33%) had undergone R0 resection, leading to closure of arm 2 but continuation to full enrollment in arm 1. The 18-month OS rate of evaluable patients was 66.7% (95% CI, 56.1%-79.4%) in arm 1 and 47.3% (95% CI 35.8%-62.5%) in arm 2. The median OS of evaluable patients in arm 1 and arm 2 was 29.8 (95% CI, 21.1-36.6) months and 17.1 (95% CI, 12.8-24.4) months, respectively. Conclusions and Relevance This randomized clinical trial found that treatment with neoadjuvant mFOLFIRINOX alone was associated with favorable OS in patients with borderline resectable PDAC compared with mFOLFIRINOX treatment plus hypofractionated radiotherapy; thus, mFOLFIRINOX represents a reference regimen in this setting. Trial Registration ClinicalTrials.gov Identifier: NCT02839343.
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Affiliation(s)
| | - Qian Shi
- Alliance Statistics and Data Management Center, Mayo Clinic, Rochester, Minnesota
| | - Jeff Meyers
- Alliance Statistics and Data Management Center, Mayo Clinic, Rochester, Minnesota
| | - Joseph M. Herman
- Northwell Cancer Institute, National Cancer Institute Community Oncology Research Program, Manhasset, New York
| | | | | | - Syed Ahmad
- University of Cincinnati, Cincinnati, Ohio
| | - Robert Marsh
- NorthShore University Health System, Evanston, Illinois
| | | | | | - Wendy L. Frankel
- The Ohio State University Arthur G James Cancer Hospital, Columbus
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Salinas-Miranda E, Healy GM, Grünwald B, Jain R, Deniffel D, O'Kane GM, Grant R, Wilson J, Knox J, Gallinger S, Fischer S, Khokha R, Haider MA. Correlation of transcriptional subtypes with a validated CT radiomics score in resectable pancreatic ductal adenocarcinoma. Eur Radiol 2022; 32:6712-6722. [PMID: 36006427 DOI: 10.1007/s00330-022-09057-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/14/2022] [Accepted: 07/24/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Transcriptional classifiers (Bailey, Moffitt and Collison) are key prognostic factors of pancreatic ductal adenocarcinoma (PDAC). Among these classifiers, the squamous, basal-like, and quasimesenchymal subtypes overlap and have inferior survival. Currently, only an invasive biopsy can determine these subtypes, possibly resulting in treatment delay. This study aimed to investigate the association between transcriptional subtypes and an externally validated preoperative CT-based radiomic prognostic score (Rad-score). METHODS We retrospectively evaluated 122 patients who underwent resection for PDAC. All treatment decisions were determined at multidisciplinary tumor boards. Tumor Rad-score values from preoperative CT were dichotomized into high or llow categories. The primary endpoint was the correlation between the transcriptional subtypes and the Rad-score using multivariable linear regression, adjusting for clinical and histopathological variables (i.e., tumor size). Prediction of overall survival (OS) was secondary endpoint. RESULTS The Bailey transcriptional classifier significantly associated with the Rad-score (coefficient = 0.31, 95% confidence interval [CI]: 0.13-0.44, p = 0.001). Squamous subtype was associated with high Rad-scores while non-squamous subtype was associated with low Rad-scores (adjusted p = 0.03). Squamous subtype and high Rad-score were both prognostic for OS at multivariable analysis with hazard ratios (HR) of 2.79 (95% CI: 1.12-6.92, p = 0.03) and 4.03 (95% CI: 1.42-11.39, p = 0.01), respectively. CONCLUSIONS In patients with resectable PDAC, an externally validated prognostic radiomic model derived from preoperative CT is associated with the Bailey transcriptional classifier. Higher Rad-scores were correlated with the squamous subtype, while lower Rad-scores were associated with the less lethal subtypes (immunogenic, ADEX, pancreatic progenitor). KEY POINTS • The transcriptional subtypes of PDAC have been shown to have prognostic importance but they require invasive biopsy to be assessed. • The Rad-score radiomic biomarker, which is obtained non-invasively from preoperative CT, correlates with the Bailey squamous transcriptional subtype and both are negative prognostic biomarkers. • The Rad-score is a promising non-invasive imaging biomarker for personalizing neoadjuvant approaches in patients undergoing resection for PDAC, although additional validation studies are required.
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Affiliation(s)
- Emmanuel Salinas-Miranda
- Lunenfeld Tanenbaum Research Institute, Sinai Health System, Mount Sinai Hospital, Joseph & Wolf Lebovic Health Complex, 600 University Avenue, 6th Floor, Office 6 200, Toronto, ON, M5G 1X5, Canada.,Joint Department of Medical Imaging, University Health Network/Sinai Health System, 600 University Ave, 5th Floor, Toronto, ON, M5G1X5, Canada
| | - Gerard M Healy
- Lunenfeld Tanenbaum Research Institute, Sinai Health System, Mount Sinai Hospital, Joseph & Wolf Lebovic Health Complex, 600 University Avenue, 6th Floor, Office 6 200, Toronto, ON, M5G 1X5, Canada.,Joint Department of Medical Imaging, University Health Network/Sinai Health System, 600 University Ave, 5th Floor, Toronto, ON, M5G1X5, Canada.,Department of Medical Imaging, University of Toronto, 263 McCaul St 4th Floor, Toronto, ON, M5T 1W5, Canada
| | - Barbara Grünwald
- Department of Pathology, University Health Network, 610 University Ave, Toronto, ON, M5G 2C1, Canada.,PanCuRx Translational Research Initiative, Ontario Institute for Cancer Research, 661 University Avenue, Suite 510, Toronto, ON, M5G 0A3, Canada
| | - Rahi Jain
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, 610 University Ave, Toronto, ON, M5G 2C1, Canada
| | - Dominik Deniffel
- Lunenfeld Tanenbaum Research Institute, Sinai Health System, Mount Sinai Hospital, Joseph & Wolf Lebovic Health Complex, 600 University Avenue, 6th Floor, Office 6 200, Toronto, ON, M5G 1X5, Canada
| | - Grainne M O'Kane
- PanCuRx Translational Research Initiative, Ontario Institute for Cancer Research, 661 University Avenue, Suite 510, Toronto, ON, M5G 0A3, Canada.,Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, 610 University Ave, Toronto, ON, M5G 2C1, Canada
| | - Robert Grant
- PanCuRx Translational Research Initiative, Ontario Institute for Cancer Research, 661 University Avenue, Suite 510, Toronto, ON, M5G 0A3, Canada.,Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, 610 University Ave, Toronto, ON, M5G 2C1, Canada
| | - Julie Wilson
- PanCuRx Translational Research Initiative, Ontario Institute for Cancer Research, 661 University Avenue, Suite 510, Toronto, ON, M5G 0A3, Canada
| | - Jennifer Knox
- PanCuRx Translational Research Initiative, Ontario Institute for Cancer Research, 661 University Avenue, Suite 510, Toronto, ON, M5G 0A3, Canada.,Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, 610 University Ave, Toronto, ON, M5G 2C1, Canada
| | - Steven Gallinger
- PanCuRx Translational Research Initiative, Ontario Institute for Cancer Research, 661 University Avenue, Suite 510, Toronto, ON, M5G 0A3, Canada.,Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, 610 University Ave, Toronto, ON, M5G 2C1, Canada.,Hepatobiliary Pancreatic Surgical Oncology Program, University Health Network, 190 Elizabeth St, Toronto, Ontario, M5G 2C4, Canada
| | - Sandra Fischer
- Department of Pathology, University Health Network, 610 University Ave, Toronto, ON, M5G 2C1, Canada
| | - Rama Khokha
- Department of Medical Biophysics, Princess Margaret Cancer Centre, University Health Network, University of Toronto, 610 University Ave, Toronto, ON, M5G 2C1, Canada
| | - Masoom A Haider
- Lunenfeld Tanenbaum Research Institute, Sinai Health System, Mount Sinai Hospital, Joseph & Wolf Lebovic Health Complex, 600 University Avenue, 6th Floor, Office 6 200, Toronto, ON, M5G 1X5, Canada. .,Joint Department of Medical Imaging, University Health Network/Sinai Health System, 600 University Ave, 5th Floor, Toronto, ON, M5G1X5, Canada. .,Department of Medical Imaging, University of Toronto, 263 McCaul St 4th Floor, Toronto, ON, M5T 1W5, Canada. .,PanCuRx Translational Research Initiative, Ontario Institute for Cancer Research, 661 University Avenue, Suite 510, Toronto, ON, M5G 0A3, Canada.
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Advances and Remaining Challenges in the Treatment for Borderline Resectable and Locally Advanced Pancreatic Ductal Adenocarcinoma. J Clin Med 2022; 11:jcm11164866. [PMID: 36013111 PMCID: PMC9410260 DOI: 10.3390/jcm11164866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/10/2022] [Accepted: 08/17/2022] [Indexed: 11/17/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) remains one of the deadliest malignancies in the United States. Improvements in imaging have permitted the categorization of patients according to radiologic involvement of surrounding vasculature, i.e., upfront resectable, borderline resectable, and locally advanced disease, and this, in turn, has influenced the sequence of chemotherapy, surgery, and radiation therapy. Though surgical resection remains the only curative treatment option, recent studies have shown improved overall survival with neoadjuvant chemotherapy, especially among patients with borderline resectable/locally advanced disease. The role of radiologic imaging after neoadjuvant therapy and the potential benefit of adjuvant therapy for borderline resectable and locally advanced disease remain areas of ongoing investigation. The advances made in the treatment of patients with borderline resectable/locally advanced disease are promising, yet disparities in access to cancer care persist. This review highlights the significant advances that have been made in the treatment of borderline resectable and locally advanced PDAC, while also calling attention to the remaining challenges.
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Prinz C, Fehring L, Frese R. MicroRNAs as Indicators of Malignancy in Pancreatic Ductal Adenocarcinoma (PDAC) and Cystic Pancreatic Lesions. Cells 2022; 11:cells11152374. [PMID: 35954223 PMCID: PMC9368175 DOI: 10.3390/cells11152374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/25/2022] [Accepted: 07/30/2022] [Indexed: 12/04/2022] Open
Abstract
The dysregulation of microRNAs has recently been associated with cancer development and progression in pancreatic ductal adenocarcinoma (PDAC) and cystic pancreatic lesions. In solid pancreatic tumor tissue, the dysregulation of miR-146, miR-196a/b, miR-198, miR-217, miR-409, and miR-490, as well as miR-1290 has been investigated in tumor biopsies of patients with PDAC and was reported to predict cancer presence. However, the value of the predictive biomarkers may further be increased during clinical conditions suggesting cancer development such as hyperinsulinemia or onset of diabetes. In this specific context, the dysregulation of miR-486 and miR-196 in tumors has been observed in the tumor tissue of PDAC patients with newly diagnosed diabetes mellitus. Moreover, miR-1256 is dysregulated in pancreatic cancer, possibly due to the interaction with long non-coding RNA molecules that seem to affect cell-cycle control and diabetes manifestation in PDAC patients, and, thus, these three markers may be of special or “sentinel value”. In blood samples, Next-generation sequencing (NGS) has also identified a set of microRNAs (miR-20a, miR-31-5p, miR-24, miR-25, miR-99a, miR-185, and miR-191) that seem to differentiate patients with pancreatic cancer remarkably from healthy controls, but limited data exist in this context regarding the prediction of cancer presences and outcomes. In contrast to solid pancreatic tumors, in cystic pancreatic cancer lesions, as well as premalignant lesions (such as intraductal papillary neoplasia (IPMN) or mucinous-cystic adenomatous cysts (MCAC)), the dysregulation of a completely different expression panel of miR-31-5p, miR-483-5p, miR-99a-5p, and miR-375 has been found to be of high clinical value in differentiating benign from malignant lesions. Interestingly, signal transduction pathways associated with miR-dysregulation seem to be entirely different in patients with pancreatic cysts when compared to PDAC. Overall, the determination of these different dysregulation “panels” in solid tumors, pancreatic cysts, obtained via fine-needle aspirate biopsies and/or in blood samples at the onset or during the treatment of pancreatic diseases, seems to be a reasonable candidate approach for predicting cancer presence, cancer development, and even therapy responses.
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Kaučić H, Kosmina D, Schwarz D, Mack A, Čehobašić A, Leipold V, Avdićević A, Mlinarić M, Lekić M, Schwarz K, Banović M. Stereotactic Body Radiotherapy for Locally Advanced Pancreatic Cancer Using Optical Surface Management System - AlignRT as an Optical Body Surface Motion Management in Deep Breath Hold Patients: Results from a Single-Arm Retrospective Study. Cancer Manag Res 2022; 14:2161-2172. [PMID: 35855763 PMCID: PMC9288179 DOI: 10.2147/cmar.s368662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 06/22/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose To assess the efficacy and safety of stereotactic body radiotherapy for patients with unresectable, locally advanced pancreatic cancer using Optical Surface Management System - AlignRT (OSMS-AlignRT) as an optical body surface motion management in deep breath hold. Patients and Methods Forty-five patients diagnosed with locally advanced pancreatic cancer were treated with stereotactic body radiotherapy in 3 or 5 fractions, and received varying BED10 (median 79.5 Gy) from April 2017 to December 2020. All patients were treated in deep breath hold with OSMS-AlignRT used as optical body surface motion management. Thirty-three patients received systemic treatment before and/or after stereotactic body radiotherapy, and twelve patients received no systemic treatment. In this retrospective, observational, single-arm study, primary endpoints were overall survival and freedom from local progression (ie, local control). Secondary endpoints were progression-free survival and toxicity. Actuarial survival analysis and univariate analysis were investigated. Results Data from forty-five patients were analyzed. Median follow-up was 15 months. One-year freedom from local progression and survival were 95.5% and 71.1%, respectively. Median progression-free survival was 14 months. Median overall survival from diagnosis for all patients was 17 months, and 19 months for patients alive at the time of analysis. No patient had >G2 toxicity. Conclusion Stereotactic body radiotherapy for locally advanced pancreatic cancer using OSMS-AlignRT as optical body surface motion management in deep breath hold patients is an effective and safe local treatment option, with no >G2 toxicity, and could be a promising therapeutic option with acceptable toxicity, either as a single treatment or in a multimodal regimen. OSMS-AlignRT provided accurate and reliable body surface motion management during stereotactic body radiotherapy.
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Affiliation(s)
- Hrvoje Kaučić
- Department of Radiosurgery and Radiotherapy, Special Hospital Radiochirurgia Zagreb, Sveta Nedelja, Croatia.,University Josip Juraj Strossmayer in Osijek - Medical Faculty Osijek, Osijek, Croatia
| | - Domagoj Kosmina
- Department of Medical Physics, Special Hospital Radiochirurgia Zagreb, Sveta Nedelja, Croatia
| | - Dragan Schwarz
- Department of Surgery, Special Hospital Radiochirurgia Zagreb, Sveta Nedelja, Croatia.,Department of Surgery, Medical Faculty of University in Rijeka, Rijeka, Croatia.,Department of Surgery, University Josip Juraj Strossmayer in Osijek - Faculty of Dental medicine and Health, Osijek, Croatia
| | - Andreas Mack
- Swiss NeuroRadiosurgery Center, Swiss Clinical NeuroScience Institute, Zürich, Switzerland
| | - Adlan Čehobašić
- University Josip Juraj Strossmayer in Osijek - Medical Faculty Osijek, Osijek, Croatia.,Department of Medical Physics, Special Hospital Radiochirurgia Zagreb, Sveta Nedelja, Croatia
| | - Vanda Leipold
- University Josip Juraj Strossmayer in Osijek - Medical Faculty Osijek, Osijek, Croatia.,Department of Medical Physics, Special Hospital Radiochirurgia Zagreb, Sveta Nedelja, Croatia
| | - Asmir Avdićević
- Department of Radiosurgery and Radiotherapy, Special Hospital Radiochirurgia Zagreb, Sveta Nedelja, Croatia
| | - Mihaela Mlinarić
- Department of Medical Physics, Special Hospital Radiochirurgia Zagreb, Sveta Nedelja, Croatia
| | - Matea Lekić
- Department of Radiosurgery and Radiotherapy, Special Hospital Radiochirurgia Zagreb, Sveta Nedelja, Croatia
| | - Karla Schwarz
- University of Zagreb, Medical Faculty, Zagreb, Croatia
| | - Marija Banović
- Department of Endocrinology, Polyclinic Leptir, Zagreb, Croatia
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Is Cell-Free DNA Testing in Pancreatic Ductal Adenocarcinoma Ready for Prime Time? Cancers (Basel) 2022; 14:cancers14143453. [PMID: 35884515 PMCID: PMC9322623 DOI: 10.3390/cancers14143453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/03/2022] [Accepted: 07/13/2022] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Pancreatic cancer is a deadly cancer with limited treatment options. It is often detected in most people at stages where cure is not possible. There is no good test to know if a person will respond to treatment or if there is any disease beyond what can be seen by available imaging tests. Genetic material from the tumor is expected to float in the blood. Studying the alterations in the genetic material could help detect the tumor early, give an idea about its aggressiveness and response to available treatments, and facilitate the discovery of newer therapies. The focus of the studies so far has been on only one kind of genetic aberration, mutations, which has not given us great results. There is a need to explore another type of change known as methylation that could hold answers for managing pancreatic cancers better. Abstract Cell-free DNA (cfDNA) testing currently does not have a significant role in PDA management: it is insufficient to diagnose PDA, and its use is primarily restricted to identifying targetable mutations (if tissue is insufficient or unavailable). cfDNA testing has the potential to address critical needs in PDA management, such as pre-operative risk stratification (POR), prognostication, and predicting (and monitoring) treatment response. Prior studies have focused primarily on somatic mutations, specifically KRAS variants, and have shown limited success in addressing prognosis and POR. Recent studies have demonstrated the importance of other less prevalent mutations (ERBB2 and TP53), but no studies have provided reliable mutation panels for clinical use. Methylation aberrations in cfDNA (epigenetic markers) in PDA have been relatively less explored. However, early evidence has suggested they offer diagnostic and, to some extent, prognostic value. The inclusion of epigenetic markers of cfDNA adds another dimension to genomic testing and may open new therapeutic avenues beyond addressing critical areas of need in PDA treatment. For cfDNA to substantially influence PDA management, concerted efforts are required to include less frequent mutations and epigenetic markers. Furthermore, relying on KRAS mutations for PDA management will always be inadequate.
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Turner KM, Delman AM, Kharofa JR, Smith MT, Choe KA, Olowokure O, Wilson GC, Patel SH, Sohal D, Ahmad SA. Radiation therapy in borderline resectable pancreatic cancer: A review. Surgery 2022; 172:284-290. [PMID: 35034793 DOI: 10.1016/j.surg.2021.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 11/11/2021] [Accepted: 12/14/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Borderline resectable pancreatic cancer constitutes a complex clinical entity, presenting the clinician with a locally aggressive disease that has a proclivity for distant spread. The benefits of radiation therapy, such as improved local control and improved survival, have been questioned. In this review we seek to summarize the existing evidence on radiation therapy in borderline resectable pancreatic cancer and highlight future areas of research. METHODS A comprehensive review of PubMed for clinical studies reporting outcomes in borderline resectable pancreatic cancer was performed in June 2021, with an emphasis placed on prospective studies. RESULTS Radiologic "downstaging" in borderline resectable pancreatic cancer is a rare event, although some evidence shows increased clinical response to neoadjuvant chemotherapy over radiation therapy. Margin status seems to be equivalent between regimens that use neoadjuvant chemotherapy alone and regimens that include neoadjuvant radiation therapy. Local control in borderline resectable pancreatic cancer is likely improved with radiation therapy; however, the benefit of improved local control in a disease marked by systemic failure has been questioned. Although some studies have shown improved survival with radiation therapy, differences in the delivery and tolerance of chemotherapy between the neoadjuvant and adjuvant setting confound these results. When the evidence is evaluated as a whole, there is no clear survival benefit of radiation therapy in borderline resectable pancreatic cancer. CONCLUSION Once considered a staple of therapy, the role of radiation therapy in borderline resectable pancreatic cancer is evolving as systemic therapy regimens continues to improve. Increased clinical understanding of disease phenotype and response are needed to accurately tailor therapy for individual patients and to improve outcomes in this complex patient population.
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Affiliation(s)
- Kevin M Turner
- Department of Surgery, University of Cincinnati College of Medicine, OH
| | - Aaron M Delman
- Department of Surgery, University of Cincinnati College of Medicine, OH
| | - Jordan R Kharofa
- Department of Radiation Oncology, University of Cincinnati College of Medicine, OH
| | - Milton T Smith
- Division of Digestive Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, OH
| | - Kyuran A Choe
- Department of Radiology, University of Cincinnati College of Medicine, OH
| | - Olugbenga Olowokure
- Division of Hematology & Oncology, Department of Internal Medicine, University of Cincinnati College of Medicine, OH
| | - Gregory C Wilson
- Department of Surgery, University of Cincinnati College of Medicine, OH; Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, OH
| | - Sameer H Patel
- Department of Surgery, University of Cincinnati College of Medicine, OH; Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, OH
| | - Davendra Sohal
- Division of Hematology & Oncology, Department of Internal Medicine, University of Cincinnati College of Medicine, OH
| | - Syed A Ahmad
- Department of Surgery, University of Cincinnati College of Medicine, OH; Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, OH.
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