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Greco SH, August DA, Shah MM, Chen C, Moore DF, Masanam M, Turner AL, Jabbour SK, Javidian P, Grandhi MS, Kennedy TJ, Alexander HR, Carpizo DR, Langan RC. Neoadjuvant therapy is associated with lower margin positivity rates after Pancreaticoduodenectomy in T1 and T2 pancreatic head cancers: An analysis of the National Cancer Database. Surg Open Sci 2021; 3:22-28. [PMID: 33490937 PMCID: PMC7807160 DOI: 10.1016/j.sopen.2020.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 11/30/2020] [Accepted: 12/04/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Neoadjuvant therapy (NAT) for T1/T2 pancreatic adenocarcinoma (PDAC) prior to pancreaticoduodenectomy remains controversial. We compared positive margin rates in patients with clinical T1&T2 tumors who did and did not receive NAT. METHODS The National Cancer Database (NCDB) found clinical T1&T2 PDAC patients who underwent pancreaticoduodenectomy from 2004 to 2014. Univariate and multivariate regression determined factors associated with a positive margin and survival. RESULTS 9795 patients underwent surgery for clinical T1 or T2 pancreatic head adenocarcinoma. 8472 patients had data regarding use of neoadjuvant and adjuvant therapies; of which, 774 (9.1%) received NAT and 435 (5.1%) received both chemotherapy and radiation therapy. NAT was found to lower positive margin rates from 21.8 to 15.5% (p < 0.0001) and when radiation was added this rate dropped to 13.4%. Positive margins were associated with worse overall survival (14.9 vs. 23.9 months; HR 1.702, p < 0.0001). CONCLUSIONS NAT is associated with a reduced positive margin rate in patients with T1 and T2 tumors. These findings support ongoing and future clinical trials of NAT in T1 and T2, early stage PDAC to determine impacts on survival.
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Affiliation(s)
- Stephanie H. Greco
- Gastrointestinal and Hepatobiliary Oncology, Rutgers Cancer Institute of New, Jersey
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School
| | - David A. August
- Gastrointestinal and Hepatobiliary Oncology, Rutgers Cancer Institute of New, Jersey
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School
- Department of Surgery, RWJBarnabas Health, Saint Barnabas Medical Center
| | - Mihir M. Shah
- Division of Surgical Oncology, Department of Surgery, Emory University
| | - Chunxia Chen
- Biostatistics, Rutgers Cancer Institute of New, Jersey
| | - Dirk F. Moore
- Biostatistics, Rutgers Cancer Institute of New, Jersey
| | - Monika Masanam
- Gastrointestinal and Hepatobiliary Oncology, Rutgers Cancer Institute of New, Jersey
| | - Amber L. Turner
- Department of Surgery, RWJBarnabas Health, Saint Barnabas Medical Center
| | - Salma K. Jabbour
- Division of Radiation Oncology, Rutgers Cancer Institute of New, Jersey
| | - Parisa Javidian
- Department of Pathology, Rutgers Robert Wood Johnson University Hospital
| | - Miral S. Grandhi
- Gastrointestinal and Hepatobiliary Oncology, Rutgers Cancer Institute of New, Jersey
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School
- Department of Surgery, RWJBarnabas Health, Saint Barnabas Medical Center
| | - Timothy J. Kennedy
- Gastrointestinal and Hepatobiliary Oncology, Rutgers Cancer Institute of New, Jersey
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School
- Department of Surgery, RWJBarnabas Health, Saint Barnabas Medical Center
| | - H. Richard Alexander
- Gastrointestinal and Hepatobiliary Oncology, Rutgers Cancer Institute of New, Jersey
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School
- Department of Surgery, RWJBarnabas Health, Saint Barnabas Medical Center
| | - Darren R. Carpizo
- Gastrointestinal and Hepatobiliary Oncology, Rutgers Cancer Institute of New, Jersey
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School
- Department of Surgery, RWJBarnabas Health, Saint Barnabas Medical Center
| | - Russell C. Langan
- Gastrointestinal and Hepatobiliary Oncology, Rutgers Cancer Institute of New, Jersey
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School
- Department of Surgery, RWJBarnabas Health, Saint Barnabas Medical Center
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Gilbert JW, Wolpin B, Clancy T, Wang J, Mamon H, Shinagare AB, Jagannathan J, Rosenthal M. Borderline resectable pancreatic cancer: conceptual evolution and current approach to image-based classification. Ann Oncol 2018; 28:2067-2076. [PMID: 28407088 DOI: 10.1093/annonc/mdx180] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background Diagnostic imaging plays a critical role in the initial diagnosis and therapeutic monitoring of pancreatic adenocarcinoma. Over the past decade, the concept of 'borderline resectable' pancreatic cancer has emerged to describe a distinct subset of patients existing along the spectrum from resectable to locally advanced disease for whom a microscopically margin-positive (R1) resection is considered relatively more likely, primarily due to the relationship of the primary tumor with surrounding vasculature. Materials and methods This review traces the conceptual evolution of borderline resectability from a radiological perspective, including the debates over the key imaging criteria that define the thresholds between resectable, borderline resectable, and locally advanced or metastatic disease. This review also addresses the data supporting neoadjuvant therapy in this population and discusses current imaging practices before and during treatment. Results A growing body of evidence suggests that the borderline resectable group of patients may particularly benefit from neoadjuvant therapy to increase the likelihood of an ultimately margin-negative (R0) resection. Unfortunately, anatomic and imaging criteria to define borderline resectability are not yet universally agreed upon, with several classification systems proposed in the literature and considerable variance in institution-by-institution practice. As a result of this lack of consensus, as well as overall small patient numbers and lack of established clinical trials dedicated to borderline resectable patients, accurate evidence-based diagnostic categorization and treatment selection for this subset of patients remains a significant challenge. Conclusions Clinicians and radiologists alike should be cognizant of evolving imaging criteria for borderline resectability given their profound implications for treatment strategy, follow-up recommendations, and prognosis.
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Affiliation(s)
- J W Gilbert
- Department of Imaging, Dana-Farber Cancer Institute.,Department of Radiology, Brigham and Women's Hospital.,Harvard Medical School
| | - B Wolpin
- Harvard Medical School.,Department of Medical Oncology, Dana-Farber Cancer Institute
| | - T Clancy
- Harvard Medical School.,Division of Surgical Oncology, Department of Surgery, Brigham and Women's Hospital
| | - J Wang
- Harvard Medical School.,Division of Surgical Oncology, Department of Surgery, Brigham and Women's Hospital.,Gastrointestinal Surgical Center, Dana-Farber/Brigham and Women's Cancer Center
| | - H Mamon
- Harvard Medical School.,Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, USA
| | - A B Shinagare
- Department of Imaging, Dana-Farber Cancer Institute.,Department of Radiology, Brigham and Women's Hospital.,Harvard Medical School
| | - J Jagannathan
- Department of Imaging, Dana-Farber Cancer Institute.,Department of Radiology, Brigham and Women's Hospital.,Harvard Medical School
| | - M Rosenthal
- Department of Imaging, Dana-Farber Cancer Institute.,Department of Radiology, Brigham and Women's Hospital.,Harvard Medical School
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Katz MHG, Shi Q, Ahmad SA, Herman JM, Marsh RDW, Collisson E, Schwartz L, Frankel W, Martin R, Conway W, Truty M, Kindler H, Lowy AM, Bekaii-Saab T, Philip P, Talamonti M, Cardin D, LoConte N, Shen P, Hoffman JP, Venook AP. Preoperative Modified FOLFIRINOX Treatment Followed by Capecitabine-Based Chemoradiation for Borderline Resectable Pancreatic Cancer: Alliance for Clinical Trials in Oncology Trial A021101. JAMA Surg 2016; 151:e161137. [PMID: 27275632 DOI: 10.1001/jamasurg.2016.1137] [Citation(s) in RCA: 310] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Although consensus statements support the preoperative treatment of borderline resectable pancreatic cancer, no prospective, quality-controlled, multicenter studies of this strategy have been conducted. Existing studies are retrospective and confounded by heterogeneity in patients studied, therapeutic algorithms used, and outcomes reported. OBJECTIVE To determine the feasibility of conducting studies of multimodality therapy for borderline resectable pancreatic cancer in the cooperative group setting. DESIGN, SETTING, AND PARTICIPANTS A prospective, multicenter, single-arm trial of a multimodality treatment regimen administered within a study framework using centralized quality control with the cooperation of 14 member institutions of the National Clinical Trials Network. Twenty-nine patients with biopsy-confirmed pancreatic cancer preregistered, and 23 patients with tumors who met centrally reviewed radiographic criteria registered. Twenty-two patients initiated therapy (median age, 64 years [range, 50-76 years]; 55% female). Patients registered between May 29, 2013, and February 7, 2014. INTERVENTIONS Patients received modified FOLFIRINOX treatment (85 mg/m2 of oxaliplatin, 180 mg/m2 of irinotecan hydrochloride, 400 mg/m2 of leucovorin calcium, and then 2400 mg/m2 of 5-fluorouracil for 4 cycles) followed by 5.5 weeks of external-beam radiation (50.4 Gy delivered in 28 daily fractions) with capecitabine (825 mg/m2 orally twice daily) prior to pancreatectomy. MAIN OUTCOMES AND MEASURES Feasibility, defined by the accrual rate, the safety of the preoperative regimen, and the pancreatectomy rate. RESULTS The accrual rate of 2.6 patients per month was superior to the anticipated rate. Although 14 of the 22 patients (64% [95% CI, 41%-83%]) had grade 3 or higher adverse events, 15 of the 22 patients (68% [95% CI, 49%-88%]) underwent pancreatectomy. Of these 15 patients, 12 (80%) required vascular resection, 14 (93%) had microscopically negative margins, 5 (33%) had specimens that had less than 5% residual cancer cells, and 2 (13%) had specimens that had pathologic complete responses. The median overall survival of all patients was 21.7 months (95% CI, 15.7 to not reached) from registration. CONCLUSIONS AND RELEVANCE The successful completion of this collaborative study demonstrates the feasibility of conducting quality-controlled trials for this disease stage in the multi-institutional setting. The data generated by this study and the logistical elements that facilitated the trial's completion are currently being used to develop cooperative group trials with the goal of improving outcomes for this subset of patients. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01821612.
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Affiliation(s)
- Matthew H G Katz
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Qian Shi
- Alliance for Clinical Trials in Oncology Statistics and Data Center, Mayo Clinic, Rochester, Minnesota
| | - Syed A Ahmad
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Joseph M Herman
- Department of Radiation Oncology, Johns Hopkins University, Baltimore, Maryland
| | - Robert de W Marsh
- Department of Medical Oncology, NorthShore University HealthSystem, University of Chicago, Chicago, Illinois
| | - Eric Collisson
- Department of Medical Oncology, University of California-San Francisco, San Francisco
| | | | - Wendy Frankel
- Department of Pathology, Ohio State University, Columbus
| | - Robert Martin
- Department of Surgery, University of Louisville, Louisville, Kentucky
| | - William Conway
- Department of Surgery, Ochsner Medical Center, New Orleans, Louisiana
| | - Mark Truty
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Hedy Kindler
- Department of Medical Oncology, University of Chicago, Chicago, Illinois
| | - Andrew M Lowy
- Department of Surgery, University of California, San Diego
| | | | - Philip Philip
- Department of Medical Oncology, Karmanos Cancer Center, Detroit, Michigan
| | - Mark Talamonti
- Department of Surgery, NorthShore University HealthSystem, University of Chicago, Chicago, Illinois
| | - Dana Cardin
- Department of Medical Oncology, Vanderbilt University, Nashville, Tennessee
| | - Noelle LoConte
- Department of Medical Oncology, University of Wisconsin-Madison, Madison, Wisconsin
| | - Perry Shen
- Department of Surgery, Wake Forest University, Winston Salem, North Carolina
| | - John P Hoffman
- Department of Surgery, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Alan P Venook
- Department of Medical Oncology, University of California-San Francisco, San Francisco
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