1
|
Ferdous KU, Tesfay MZ, Cios A, Shelton RS, Hartupee C, Urbaniak A, Chamcheu JC, Mavros MN, Giorgakis E, Mustafa B, Simoes CC, Miousse IR, Basnakian AG, Moaven O, Post SR, Cannon MJ, Kelly T, Nagalo BM. Enhancing Neoadjuvant Virotherapy's Effectiveness by Targeting Stroma to Improve Resectability in Pancreatic Cancer. Biomedicines 2024; 12:1596. [PMID: 39062169 PMCID: PMC11275208 DOI: 10.3390/biomedicines12071596] [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: 06/24/2024] [Revised: 07/15/2024] [Accepted: 07/16/2024] [Indexed: 07/28/2024] Open
Abstract
About one-fourth of patients with pancreatic ductal adenocarcinoma (PDAC) are categorized as borderline resectable (BR) or locally advanced (LA). Chemotherapy and radiation therapy have not yielded the anticipated outcomes in curing patients with BR/LA PDAC. The surgical resection of these tumors presents challenges owing to the unpredictability of the resection margin, involvement of vasculature with the tumor, the likelihood of occult metastasis, a higher ratio of positive lymph nodes, and the relatively larger size of tumor nodules. Oncolytic virotherapy has shown promising activity in preclinical PDAC models. Unfortunately, the desmoplastic stroma within the PDAC tumor microenvironment establishes a barrier, hindering the infiltration of oncolytic viruses and various therapeutic drugs-such as antibodies, adoptive cell therapy agents, and chemotherapeutic agents-in reaching the tumor site. Recently, a growing emphasis has been placed on targeting major acellular components of tumor stroma, such as hyaluronic acid and collagen, to enhance drug penetration. Oncolytic viruses can be engineered to express proteolytic enzymes that cleave hyaluronic acid and collagen into smaller polypeptides, thereby softening the desmoplastic stroma, ultimately leading to increased viral distribution along with increased oncolysis and subsequent tumor size regression. This approach may offer new possibilities to improve the resectability of patients diagnosed with BR and LA PDAC.
Collapse
Affiliation(s)
- Khandoker Usran Ferdous
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (K.U.F.); (M.Z.T.); (A.C.); (C.C.S.); (S.R.P.); (T.K.)
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (M.N.M.); (M.J.C.)
| | - Mulu Z. Tesfay
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (K.U.F.); (M.Z.T.); (A.C.); (C.C.S.); (S.R.P.); (T.K.)
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (M.N.M.); (M.J.C.)
| | - Aleksandra Cios
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (K.U.F.); (M.Z.T.); (A.C.); (C.C.S.); (S.R.P.); (T.K.)
| | - Randal S. Shelton
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA;
| | - Conner Hartupee
- Division of Surgical Oncology, Department of Surgery, Louisiana State University (LSU) Health, New Orleans, LA 70112, USA; (C.H.); (O.M.)
| | - Alicja Urbaniak
- Department of Biochemistry and Molecular Biology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (A.U.); (I.R.M.)
| | - Jean Christopher Chamcheu
- Department of Biological Sciences and Chemistry, Southern University and A&M College, Baton Rouge, LA 70813, USA;
- Division of Biotechnology and Molecular Medicine, Department of Pathobiological Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA 70803, USA
| | - Michail N. Mavros
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (M.N.M.); (M.J.C.)
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA;
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA;
| | - Emmanouil Giorgakis
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA;
| | - Bahaa Mustafa
- Department of Pharmaceutical Sciences, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA;
| | - Camila C. Simoes
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (K.U.F.); (M.Z.T.); (A.C.); (C.C.S.); (S.R.P.); (T.K.)
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (M.N.M.); (M.J.C.)
| | - Isabelle R. Miousse
- Department of Biochemistry and Molecular Biology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (A.U.); (I.R.M.)
| | - Alexei G. Basnakian
- Department of Pharmacology and Toxicology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA;
- Central Arkansas Veterans Healthcare System, John L. McClellan Memorial VA Hospital, Little Rock, AR 72205, USA
| | - Omeed Moaven
- Division of Surgical Oncology, Department of Surgery, Louisiana State University (LSU) Health, New Orleans, LA 70112, USA; (C.H.); (O.M.)
- Department of Interdisciplinary Oncology, Louisiana Cancer Research Center, Louisiana State University (LSU) Health, New Orleans, LA 70112, USA
| | - Steven R. Post
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (K.U.F.); (M.Z.T.); (A.C.); (C.C.S.); (S.R.P.); (T.K.)
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (M.N.M.); (M.J.C.)
| | - Martin J. Cannon
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (M.N.M.); (M.J.C.)
- Department of Microbiology and Immunology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
| | - Thomas Kelly
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (K.U.F.); (M.Z.T.); (A.C.); (C.C.S.); (S.R.P.); (T.K.)
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (M.N.M.); (M.J.C.)
| | - Bolni Marius Nagalo
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (K.U.F.); (M.Z.T.); (A.C.); (C.C.S.); (S.R.P.); (T.K.)
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (M.N.M.); (M.J.C.)
| |
Collapse
|
2
|
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.
Collapse
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.
| |
Collapse
|
3
|
Teng F, Meng L, Zhu F, Ren G. Dosimetric feasibility on hypofractionated intensity-modulated radiotherapy and simultaneous integrated boost for locally advanced unresectable pancreatic cancer with helical tomotherapy. J Gastrointest Oncol 2021; 12:496-506. [PMID: 34012643 DOI: 10.21037/jgo-21-160] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background This dosimetric study on locally advanced pancreatic cancer (LAPC) and the surrounding gastrointestinal organs at risk (OARs) aimed at exploring the potential of further improving the internal dose and reducing the fractionation number by concurrent hypofractionated simultaneous integrated boost (SIB) radiotherapy using helical tomotherapy (HT). Methods We collected computed tomography positioning images from a LAPC study of 17 consecutive patients. Gross tumor volume (GTV)1, GTV2, and GTV3 were defined as the GTV minus a margin of 3, 6, and 9 mm from the external part in all directions, respectively. Under the same physical parameters and limited dose on normal organs, each case had 4 sets of SIB radiotherapy plans. Upon dose escalation, we statistically analyzed the difference of dosimetric parameters received by the OARs between group A [planning target volume (PTV)/GTV=50 Gy/70 Gy] and the other groups. According to the equivalent bioradiotherapy formula, we calculated the hypofractionated standard dose by converting the average tolerated dose of each OAR with the corresponding number of fractions. Then, we compared the dose and volume parameters of the gastrointestinal tract from the less-than-20-fraction modes with the corresponding gastrointestinal hypofractionated standard dose. Results For dose escalation, although there were a few differences in the parameters of the OAR between group A and group D, all OAR doses of group D (PTV/GTV/GTV1/GTV2/GTV3=50 Gy/70 Gy/80 Gy/90 Gy/100 Gy) were within the limited dose range. In the hypofractionated mode, there was a statistically significant difference between the gastrointestinal dose-volume parameters and the dose-limiting reference standard when the fraction number was less than 14 or 15 for group A or D, respectively. Conclusions The dose of the internal target can be increased to 100 Gy with 15 fractions in the hypofractionated SIB radiotherapy for LAPC with HT. The corresponding tolerance dose of OARs may also be acceptable.
Collapse
Affiliation(s)
- Feng Teng
- Department of Radiation Oncology, China-Japan Friendship Hospital, Beijing, China
| | - Lingling Meng
- Department of Radiotherapy, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Fuhai Zhu
- Department of Radiotherapy, Air Force Medical Center of PLA, Beijing, China
| | - Gang Ren
- Department of Radiotherapy, Air Force Medical Center of PLA, Beijing, China
| |
Collapse
|
4
|
Lindemann J, du Toit L, Kotze U, Bernon M, Krige J, Jonas E. Survival equivalence in patients treated for borderline resectable and unresectable locally advanced pancreatic ductal adenocarcinoma: a systematic review and network meta-analysis. HPB (Oxford) 2021; 23:173-186. [PMID: 33268268 DOI: 10.1016/j.hpb.2020.09.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/04/2020] [Accepted: 09/29/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The clinical relevance of subdivision of non-metastatic pancreatic ductal adenocarcinoma (PDAC) into locally advanced borderline resectable (LA-BR) and locally advanced unresectable (LA-UR) has been questioned. We assessed equivalence of overall survival (OS) in patients with LA-BR and LA-UR PDAC. METHODS A systematic review was performed of studies published January 1, 2009 to August 21, 2019, reporting OS for LA-BR and LA-UR patients treated with or without neoadjuvant therapy (NAT), with or without surgical resection. A frequentist network meta-analysis was used to assess the primary outcome (hazard ratio for OS) and secondary outcomes (OS in LA-BR, LA-UR, and upfront resectable (UFR) PDAC). RESULTS Thirty-nine studies, comprising 14,065 patients in a network of eight unique treatment subgroups were analysed. Overall survival was better for LA-BR than LA-UR patients following surgery both with and without NAT. Neoadjuvant therapy prior to surgery was associated with longer OS for UFR, LA-BR, and LA-UR tumours, compared to upfront surgery. CONCLUSION Survival between the LA-BR and LA-UR subgroups was not equivalent. This subdivision is useful for prognostication, but likely unhelpful in treatment decision making. Our data supports NAT regardless of initial disease extent. Individual patient data assessment is needed to accurately estimate the benefit of NAT.
Collapse
Affiliation(s)
- Jessica Lindemann
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa; Department of Surgery, Washington University School of Medicine, 660 South Euclid Ave, Saint Louis, MO, 63110, USA
| | - Leon du Toit
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Urda Kotze
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Marc Bernon
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Jake Krige
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Eduard Jonas
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa.
| |
Collapse
|
5
|
Treatment Strategies for the Optimal Management of Locally Advanced Pancreatic Adenocarcinoma With Curative Intent: A Systematic Review. Pancreas 2020; 49:1264-1275. [PMID: 33122513 DOI: 10.1097/mpa.0000000000001694] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Historically, locally advanced pancreatic adenocarcinoma (LAPDAC) was considered a palliative condition. Advances in treatment have resulted in studies reporting survival after neoadjuvant treatment and surgery similar to earlier disease stages. However, there is no consensus on optimal LAPDAC management. Our aim was a systematic review of published evidence on LAPDAC treatment strategies with curative intent. Twenty-eight studies defining LAPDAC as per established criteria and reporting outcomes after neoadjuvant treatment with a view to resection were included. Primary outcomes were resection rate and proportion of curative resections. Secondary outcomes were postoperative mortality, progression-free survival, and overall survival. Neoadjuvant treatment varied significantly, most common being the combination of folinic acid, fluorouracil, irontecan, and oxaliplatin. Median percentage of patients proceeding to surgery after completion of neoadjuvant pathway was 33.5%. Median resection rate was 25%. Median R0 resection was 80% of resected patients. These outcomes ranged 0% to 100% across studies. Ninety-day postoperative mortality ranged from 0% to 5%. Median progression-free and overall survival for resected patients were 12.9 and 30 months, respectively, versus 13.2 months overall survival for unresected patients. In conclusion, although there is wide variability in reported LAPDAC resection rates post-neoadjuvant chemotherapy, retrospective data suggest that neoadjuvant treatment followed by surgery results in improved survival.
Collapse
|
6
|
Gupta P, Totti S, Pérez-Mancera PA, Dyke E, Nisbet A, Schettino G, Webb R, Velliou EG. Chemoradiotherapy screening in a novel biomimetic polymer based pancreatic cancer model. RSC Adv 2019; 9:41649-41663. [PMID: 35541584 PMCID: PMC9076463 DOI: 10.1039/c9ra09123h] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 12/09/2019] [Indexed: 11/21/2022] Open
Abstract
Pancreatic Ductal Adenocarcinoma (PDAC) is a deadly and aggressive disease with a very low survival rate. This is partly due to the resistance of the disease to currently available treatment options. Herein, we report for the first time the use of a novel polyurethane scaffold based PDAC model for screening the short and relatively long term (1 and 17 days post-treatment) responses of chemotherapy, radiotherapy and their combination. We show a dose dependent cell viability reduction and apoptosis induction for both chemotherapy and radiotherapy. Furthermore, we observe a change in the impact of the treatment depending on the time-frame, especially for radiation for which the PDAC scaffolds showed resistance after 1 day but responded more 17 days post-treatment. This is the first study to report a viable PDAC culture in a scaffold for more than 2 months and the first to perform long-term (17 days) post-treatment observations in vitro. This is particularly important as a longer time-frame is much closer to animal studies and to patient treatment regimes, highlighting that our scaffold system has great potential to be used as an animal free model for screening of PDAC. Poly-urethane scaffold based 3D pancreatic cancer model enables realistic long term chemotherapy and radiotherapy screening. This model can be used for personalised treatment screening.![]()
Collapse
Affiliation(s)
- Priyanka Gupta
- Bioprocess and Biochemical Engineering Group (BioProChem)
- Department of Chemical and Process Engineering
- University of Surrey
- Guildford
- UK
| | - Stella Totti
- Bioprocess and Biochemical Engineering Group (BioProChem)
- Department of Chemical and Process Engineering
- University of Surrey
- Guildford
- UK
| | | | - Eleanor Dyke
- Department of Medical Physics
- The Royal Surrey County Hospital
- NHS Foundation Trust
- Guildford
- UK
| | - Andrew Nisbet
- Department of Medical Physics
- The Royal Surrey County Hospital
- NHS Foundation Trust
- Guildford
- UK
| | - Giuseppe Schettino
- Department of Physics
- University of Surrey
- Guildford GU2 7XH
- UK
- Medical Radiation Science Group
| | - Roger Webb
- The Ion Beam Centre
- University of Surrey
- Guildford
- UK
| | - Eirini G. Velliou
- Bioprocess and Biochemical Engineering Group (BioProChem)
- Department of Chemical and Process Engineering
- University of Surrey
- Guildford
- UK
| |
Collapse
|