S-1 in the treatment of pancreatic cancer

Safety and efficacy of S1 monotherapy or combined with nab-paclitaxel in advanced elderly pancreatic cancer patients: A meta-analysis

OBJECTIVE

To evaluate the therapeutic efficacy and safety of S1 monotherapy or combination with nab-paclitaxel for the treatment of elderly patients with metastatic or locally advanced pancreatic adenocarcinoma.

METHOD

PubMed, Embase, Cochrane Central Library, China Biology Medicine, and China National Knowledge Infrastructure databases were searched without time limits according to the inclusion criteria. RevMan (Version 5.3) software was used for data extraction and meta-analysis. Objective response rate (ORR) and disease control rate (DCR) were used to evaluate therapeutic effects while side effects including leukopenia, thrombocytopenia, neurotoxicity, vomit, and alopecia were extracted for evaluation. There was no need for ethical review in this study because no ethical experiments were conducted and all data used were public data. All relevant data are within the paper and its Supporting Information files.

RESULTS

Four retrospective studies comprising 308 elderly patients with metastatic or locally advanced pancreatic adenocarcinoma were included in the analysis. One hundred fifty-one patients underwent S1 monotherapy and 157 received S1 combined nab-paclitaxel. Meta-analysis indicated that compared with S1 monotherapy, S1 combined with nab-paclitaxel had higher ORR (OR 2.25, 95% CI: 1.42-3.55; P = .0005) and DCR (OR 2.94, 95% CI: 1.55-5.58; P = .0009). The adverse reaction of leukopenia was higher in the combined therapy group (OR 1.85, 95% CI: 1.09-3.13, P = .02), but no significant difference was found in thrombocytopenia, neurotoxicity, vomiting, and alopecia between the 2 groups (P > .05).

CONCLUSION

Nab-paclitaxel plus S1 was more efficient in terms of ORR and DCR than S1 monotherapy in elderly pancreatic ductal adenocarcinoma patients while the side effect was controllable with a higher probability of leukopenia. Thus, combined nab-paclitaxel and S1 could be safely used in elderly patients.

Comparison of 4- and 4 plus-courses S-1 administration as adjuvant chemotherapy for pancreatic ductal adenocarcinoma

Purpose

The study aimed to investigate the potential benefit of more than 4 courses of S1 adjuvant chemotherapy for patients with pancreatic ductal adenocarcinoma (PDAC) after surgery.

Method

Data were retrospectively collected from consecutive patients who underwent S-1 adjuvant chemotherapy following curative pancreatectomy between January 2016 and December 2018.

Four-courses and > 4 courses cohorts were compared for overall survival (OS) as a primary outcome, and relapse-free survival (RFS) and adverse event incidence as secondary outcomes.

Results

Four-courses and > 4 courses cohorts comprised 99 patients and 64 ones, respectively. TNM stage (stage II vs. I: HR, 2.125; 95% CI, 1.164–4.213; P = 0.015), duration of S-1 administration (4 vs. > 4 courses: HR, 3.113; 95% CI, 1.531–6.327; P = 0.002) and tumor grade (G3 vs. G1/2: HR, 3.887; 95% CI, 1.922–7.861; P < 0.001) were independent prognostic factors. Under the condition of patients’ survival time beyond 8 months, the OS of patients in > 4 courses cohort was significantly prolonged compared with that of 4 courses cohort (4 vs. > 4 courses: HR, 2.284; 95% CI, 1.197–4.358; P = 0.012), especially for patients in TNM stageII (4 vs. > 4 courses: HR, 2.906; 95% CI, 1.275–6.623; P = 0.011).RFS and adverse events incidence did not signifcantly difer between both cohorts.

Conclusion

Prolonged duration of S-1 intake is beneficial to prognosis of patients with PDAC resection.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08380-9.

Neutralization of Acidic Tumor Microenvironment (TME) with Daily Oral Dosing of Sodium Potassium Citrate (K/Na Citrate) Increases Therapeutic Effect of Anti-cancer Agent in Pancreatic Cancer Xenograft Mice Model

Extracellular pH (pHe) of tumor cells is characteristic of tumor microenvironment (TME). Acidic TME impairs the responses of tumors to some anti-cancer chemotherapies. In this study, we showed that daily oral dosing of sodium potassium citrate (K/Na citrate) increased blood HCO₃^- concentrations, corresponding to increase of HCO₃^- concentrations and pHs in urine, and neutralized the tumor pHe. Neutralization of acidic TME by alkaline substance like HCO₃^-, an active metabolite of K/Na citrate, well potentiated the therapeutic effect of anticancer agent TS-1^®, an orally active 5-fuluoro-uracil derivative, in Panc-1 pancreatic cancer-xenograft murine model. Neutralization of acidic TME by using an alkaline K/Na citrate is a smart approach for enhancement of the therapeutic effects of anticancer agents for pancreatic cancer in the end stage.

CC Chemokine Receptor 2-Targeting Copper Nanoparticles for Positron Emission Tomography-Guided Delivery of Gemcitabine for Pancreatic Ductal Adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) is a deadly malignancy with dire prognosis due to aggressive biology, lack of effective tools for diagnosis at an early stage, and limited treatment options. Detection of PDAC using conventional radiographic imaging is limited by the dense, hypovascular stromal component and relatively scarce neoplastic cells within the tumor microenvironment (TME). The CC motif chemokine 2 (CCL2) and its cognate receptor CCR2 (CCL2/CCR2) axis are critical in fostering and maintaining this kind of TME by recruiting immunosuppressive myeloid cells such as the tumor-associated macrophages, thereby presenting an opportunity to exploit this axis for both diagnostic and therapeutic purposes. We engineered CCR2-targeting ultrasmall copper nanoparticles (Cu@CuOx) as nanovehicles not only for targeted positron emission tomography imaging by intrinsic radiolabeling with 64Cu but also for loading and delivery of the chemotherapy drug gemcitabine to PDAC. This 64Cu-radiolabeled nanovehicle allowed sensitive and accurate detection of PDAC malignancy in autochthonous genetically engineered mouse models. The ultrasmall Cu@CuOx showed efficient renal clearance, favorable pharmacokinetics, and minimal in vivo toxicity. Systemic administration of gemcitabine-loaded Cu@CuOx effectively suppressed the progression of PDAC tumors in a syngeneic xenograft mouse model and prolonged survival. These CCR2-targeted ultrasmall nanoparticles offer a promising image-guided therapeutic agent and show great potential for translation.

The Present Status of Immuno-Oncolytic Viruses in the Treatment of Pancreatic Cancer

Pancreatic ductal adenocarcinoma (PDAC) is the fifth leading cause of cancer-related death in Western countries. The incidence of PDAC has increased over the last 40 years and is projected to be the second leading cause of cancer death by 2030. Despite aggressive treatment regimens, prognosis for patients diagnosed with PDAC is very poor; PDAC has the lowest 5-year survival rate for any form of cancer in the United States (US). PDAC is very rarely detected in early stages when surgical resection can be performed. Only 20% of cases are suitable for surgical resection; this remains the only curative treatment when combined with adjuvant chemotherapy. Treatment regimens excluding surgical intervention such as chemotherapeutic treatments are associated with adverse effects and genetherapy strategies also struggle with lack of specificity and/or efficacy. The lack of effective treatments for this disease highlights the necessity for innovation in treatment options for patients diagnosed with early- to late-phase PDAC and immuno-oncolytic viruses (OVs) have been of particular interest since 2006 when the first oncolytic virus was approved as a therapy for nasopharyngeal cancers in China. Interest resurged in 2015 when T-Vec, an oncolytic herpes simplex virus, was approved in the United States for treatment of advanced melanoma. While many vectors have been explored, few show promise as treatment for pancreatic cancer, and fewer still have progressed to clinical trial evaluation. This review outlines recent strategies in the development of OVs targeting treatment of PDAC, current state of preclinical and clinical investigation and application.

Efficacy of S-1 in second-line chemotherapy after nab-paclitaxel plus gemcitabine for patients with advanced pancreatic cancer

BACKGROUND

Second-line (2 L) chemotherapy is important for improved survival. However, the efficacy of S-1 after nab-paclitaxel plus gemcitabine (AG) for advanced pancreatic cancer (APC) remains unclear.

AIM

We retrospectively investigated the clinical impact of S-1 after AG.

METHODS AND RESULTS

From January 2015 to July 2018, 37 patients with APC underwent AG as first-line chemotherapy at our institute. Of these patients, 14 (38%) underwent S-1 as 2 L chemotherapy after AG (S-1 group), five (14%) received another agent after AG, and 18 (49%) underwent no 2 L chemotherapy (best supportive care [BSC] group). The clinical features were retrospectively compared between the S-1 and BSC groups. Prognostic factors for residual survival (RS) were analyzed using a Cox proportional hazards model. The induction rate of 2 L chemotherapy was 51%, and most patients received S-1 monotherapy (74%). The disease control rate and progression-free survival duration were 57.1% and 2.8 months, respectively. The median RS duration in the S-1 and BSC groups was 5.2 and 2.4 months, respectively; this difference was statistically significant (hazard ratio, 0.33; P = .005). The median overall survival duration in the S-1 and BSC groups was 12.3 and 5.0 months, respectively; this difference was also statistically significant (hazard ratio, 0.26; P = .001). The efficacy of S-1 in 2L chemotherapy for RS was identified in the multivariate analysis, as was age (<65 vs ≥65 y) and the presence of liver metastasis.

CONCLUSION

The antitumor activity of S-1 was retained after AG, and the induction of S-1 after AG might improve the prognosis of patients with APC.

Total Pancreatectomy with Splenectomy for Multifocal Intraductal Tubulopapillary Neoplasm (ITPN) of the Pancreas Associated with Invasive Component: Report of a Rare Case

Patient: Male, 82-year-old

Final Diagnosis: Pancreatic intraductal tubulopappilary neoplasm (ITPN)

Symptoms: Abdominal pain • anorexia • weakness • weight loss

Medication: Amlodipine 5 mg/valsartan 160 mg • nebivolol 5 mg • metformin 850 mg • pancreatin 25 000 IU

Clinical Procedure: Total pancreatectomy with splenectomy

Specialty: Oncology • Pathology • Radiology • Surgery

Area of residual tumor (ART) can predict prognosis after post neoadjuvant therapy resection for pancreatic ductal adenocarcinoma

An increasing number of patients with pancreatic ductal adenocarcinoma (PDAC) have undergone resection after neoadjuvant therapy (NAT). We have reported Area of Residual Tumor (ART) as a useful pathological assessment method to predict patient outcomes after post NAT resection in various cancer types. The aim of this study was to assess the prognostic performance of ART in PDAC resected after NAT. Sixty-three patients with PDAC after post NAT resection were analyzed. The viable residual tumor area was outlined and the measurement of ART was performed using morphometric software. The results were compared with those of the College of American Pathologist (CAP) regression grading. Of 63 cases, 39 (62%) patients received chemoradiation therapy and 24 (38%) received chemotherapy only. The median value of ART was 163 mm2. Large ART with 220 mm2 as the cut-off was significantly associated with lymphatic invasion, vascular invasion and perineural invasion, while CAP regression grading was not associated with any clinicopathological features. By multivariate analysis, large ART (≥220 mm2) was an independent predictor of shorter relapse free survival. Together with our previous reports, an ART-based pathological assessment may become a useful method to predict patient outcomes after post NAT resection across various cancer types.

Oral chemotherapy for second-line treatment in patients with gemcitabine-refractory advanced pancreatic cancer

BACKGROUND

There is no standard therapy for second-line treatment of gemcitabine-refractory pancreatic cancer patients with poor performance status. A combination of chemotherapy drugs 5-fluorouracil (5-FU), leucovorin, irinotecan, and oxaliplatin (FOLFIRINOX) or 5-fluorouracil/leucovorin plus nanoliposomal irinotecan can be considered as second-line treatment for such patients; however, due to toxicity, none of the regimens are recommended for patients with poor performance. Capecitabine or S-1 has relatively low toxicity and can be considered a treatment option for gemcitabine-refractory pancreatic cancer.

AIM

To investigate the efficacy and toxicity of oral chemotherapy as second-line treatment in patients with pancreatic cancer.

METHODS

Patients who had progressive disease after first-line gemcitabine-based chemotherapy were retrospectively analyzed between January 2011 and December 2018. They were treated with capecitabine or S-1 as the second-line treatment. Capecitabine was administered as a 2500 mg/m² divided dose on days 1-14, followed by a 1-wk rest. S-1 was taken orally based on the patient’s body surface area for 28 d, followed by 2-wk of rest. Progression-free survival and overall survival were used to compare efficacy of capecitabine and S-1.

RESULTS

Of the 81 patients, 41 were treated with capecitabine and 40 with S-1. The median time to treatment failure in both groups was 1.5 mo (P = 0.425). The objective response rate was similar in the two groups: 9.8% with capecitabine and 2.5% with S-1 (P = 0.359). Median progression-free survival was longer in the S-1 group than in the capecitabine group (S-1 2.7 mo, capecitabine 2.0 mo, P = 0.003). There was no significant difference in the median overall survival between the capecitabine and S-1 groups (4.3 mo vs 5.0 mo, P = 0.092). Grade 3 or 4 hand-foot syndrome was significantly more common in the capecitabine group than in the S-1 group (14.6% vs 0%, P = 0.026).

CONCLUSION

Capecitabine or S-1 can be used as a second-line treatment for patients with advanced pancreatic cancer with poor performance status after progression to a gemcitabine-based regimen.

Xenografts Derived From Patients' Ascites Recapitulate the Gemcitabine Resistance Observed in Pancreatic Cancer Patients

OBJECTIVES

Most patient-derived pancreatic ductal adenocarcinoma (PDAC) xenografts have been established from surgical specimens of patients who have not received chemotherapy. However, xenografts have rarely been established from chemotherapy-resistant, advanced PDACs, because such cases are usually inoperable. The purpose of this study is to establish patient-derived xenografts using PDAC cells refractory to chemotherapy.

METHODS

Clinical PDAC cells obtained from ascites of patients who had received continuous chemotherapy were implanted into the flanks of immunocompromised mice. Growth and histological features of the xenografts with and without gemcitabine treatment were then analyzed.

RESULTS

Ascites-derived PDAC cells were successfully expanded through serial xenograft passage without changes in histological appearance. While treatment with gemcitabine substantially inhibited the growth of all PDAC xenografts tested, the tumor volume gradually increased, and the tumors showed marked regrowth even under continued gemcitabine treatment. These findings are consistent with the actual clinical course of the corresponding patients for each xenograft.

CONCLUSIONS

Ascites-derived xenograft models represent a valuable experimental system for testing the efficacy of currently available therapeutic compounds on chemotherapy-resistant PDAC cells and for elucidation of the mechanisms underlying chemotherapy resistance.

Is hepatic artery coil embolization useful in distal pancreatectomy with en bloc celiac axis resection for locally advanced pancreatic cancer?

BACKGROUND

The exact contribution of preoperative coil embolization in distal pancreatectomy with en bloc celiac axis resection (DP-CAR) for the prevention of ischemic liver complication is not fully elucidated.

METHODS

From January 2004 to July 2015, 31 patients underwent DP-CAR for the pancreatic body-tail cancer. Twenty-three patients received preoperative coil embolization. The characteristics and operative outcomes were analyzed retrospectively.

RESULTS

The median survival time and 1- and 3-year overall survival rates were 23.7 months and 74.2% and 34.4%, respectively. No 30-day mortality occurred in any of the patients. Postoperative liver infarction developed only in 8 patients (25.8%) even though 7 of 8 patients had undergone preoperative coil embolization. Tumor contact with the gastroduodenal artery (GDA)/proper hepatic artery (PHA) on preoperative multi-detector computed tomography (MDCT), tumor size, operative time, portal vein resection, and stenosis of the GDA/PHA after DP-CAR are related to liver infarction. Among them, postoperative stenosis of the GDA/PHA on MDCT, which was observed in all 8 patients with liver infarction, was the most closely related factor to postoperative liver infarction. Tumor contact with the GDA/PHA did not worsen the R0 resection rate or overall survival rate.

CONCLUSION

Our data indicate that preoperative coil embolization of the common hepatic artery is not useful in DP-CAR as long as GDA is completely preserved during surgery.

Remnant pancreatic volume as an indicator of poor prognosis in pancreatic cancer patients after resection

BACKGROUND

Remnant pancreatic volume (RPV) is a well-known marker for short-term outcomes in pancreatic cancer patients after resection. However, in terms of the long-term outcomes, the significance of the RPV value remains unclear. Here, we address whether the RPV value is a predictor of the long-term outcomes in pancreatic cancer patients after resection by comparing various cancer-, patient-, and surgery-related prognostic factors and systemic inflammatory response markers in a retrospective cohort.

METHODS

The RPV was measured on a three-dimensional (3D) image, revealing the actual pancreatic parenchymal remnant volume. Ninety-one patients who underwent pancreaticoduodenectomy were retrospectively enrolled. We divided the cohort into high- and low-RPV groups based on a cut-off value (>31.5 cm³, n = 66 and ≤31.5 cm³, n = 25, respectively). The median survival times (MSTs) were compared between the two groups. Using multivariate analysis, the RPV and other well-known prognostic factors were independently assessed.

RESULTS

The MSTs (days) were significantly different between the two groups (high, 823 vs. low, 482, p = 0.001). Multivariate analysis identified the RPV (≤31.5 cm³) (hazard ratio [HR], 2.015; p = 0.011), lymph node metastasis (HR, 8.415; p = 0.002), lack of adjuvant chemotherapy (HR, 5.352; p < 0.001), stage III/IV disease (HR, 2.352; p = 0.029), and pathological fibrosis (HR, 1.771; p = 0.031) as independent prognostic factors.

CONCLUSIONS

The present study suggests that the RPV value is also useful for predicting long-term outcomes in pancreatic cancer patients after resection.

Efficacy of S-1 monotherapy for older patients with unresectable pancreatic cancer: A retrospective cohort study

OBJECTIVES

Pancreatic cancer is a fatal malignancy that frequently occurs in older patients. However, limited evidence is available on the effects of chemotherapy on older patients with unresectable pancreatic cancer. Here we explored the efficacy of S-1, an oral fluorouracil drug, compared with gemcitabine, as first-line chemotherapy.

MATERIALS AND METHODS

We conducted a retrospective cohort study of patients with unresectable pancreatic cancer aged ≥75 years. For this purpose, we used the claims and master databases of the Fukuoka Prefecture Wide-Area Association of Latter-Stage Elderly Healthcare between April 1, 2010 to March 31, 2017. According to first-line chemotherapy, we divided patients into gemcitabine and S-1 groups to compare three-year survival from the date of diagnosis and time to second-line chemotherapy as a surrogate indicator of progression-free survival. We analyzed the data using multivariate Cox proportional hazards method.

RESULTS

The study comprised 680 patients, of which 92.5% (N = 629) died within three years of diagnosis. The S-1 group had a significantly lower risk of death within three years of diagnosis (hazard ratio (HR) 0.695, 95% CI: 0. 588-0. 821, p < .001). There were no significant differences (HR 0.968, 95% CI: 0.708-1.324, p = .838) in time to second-line chemotherapy. Two sensitivity analyses excluding study subjects who received radiation therapy or second-line chemotherapy yielded consistent results (HR 0.746, 95% CI: 0.622-0.895, p = .002, HR 0.628, 95% CI: 0. 509-0.776, p < .001, respectively).

CONCLUSION

S-1 can serve as a first-line chemotherapeutic option of patients aged ≥75 years with unresectable pancreatic cancer.

Phase II Study of S-1 plus Cisplatin as First-Line Therapy in Patients with Metastatic Esophageal Carcinoma

BACKGROUND

Patients with metastatic esophageal squamous cell cancer (ESCC) need safer and more efficacious treatments. The aim of this phase II study was to investigate the efficacy and safety of S-1 plus cisplatin as first-line therapy in metastatic ESCC.

PATIENTS AND METHODS

50 patients with metastatic ESCC who had not received prior systemic chemotherapy for metastatic disease were enrolled. Patients received S-1 at 40 mg/m2 divided into 2 daily doses for 14 days and cisplatin at 75 mg/m2 on day 1 or 25 mg/m2 on days 1-3 intravenously, repeated every 21 days with a maximum of 6 cycles.

RESULTS

47 patients were assessable for response and 18 patients achieved a partial response, giving an overall response rate of 38.3%. Among those who had objective responses, a large percentage (72.2%) quickly showed remarkable tumor shrinkage during the first 2 cycles. 18 (38.3%) patients had stable disease. The median progression-free survival was 5.6 months, and the median overall survival was 12.0 months. Toxicity was mild to moderate and generally tolerable.

CONCLUSION

The combination of S-1 plus cisplatin was a well-tolerated and convenient chemotherapy regimen with promising efficacy.

Gemcitabine plus S-1 for metastatic pancreatic cancer

To investigate the treatment effects of gemcitabine plus S-1 (GS) for metastatic pancreatic cancer in our institution.Data from 41 patients with metastatic pancreatic cancer treated with GS regimen in West China Hospital, Sichuan University were reviewed. The therapeutic efficacy and toxicity were evaluated. The influencing factors of progression-free survival (PFS) and overall survival (OS) were also explored.At the last follow-up, all patients had died. The objective response rate was 22.0% (9/41) and the disease control rate was 65.9% (27/41). The median PFS and OS times were 5.1 (range, 1.5-21) and 10.6 months (range, 1.5-40), respectively. The 0.5-, 1-, and 2-year OS rates were 65.9%, 41.5%, and 9.8%, respectively. In multivariate analysis, body mass index and carbohydrate antigen 19-9 change were the significant influencing factors of PFS, compared to tumor site and chemotherapy cycles for OS. The adverse effects were moderate and tolerable.The effects of GS for metastatic pancreatic cancer in our institution were good. The adverse effects were moderate and tolerable. However, further investigation in future prospective clinical studies is warranted.

Successful gamma knife radiosurgery combined with S-1 in an elderly man with local recurrent pancreatic cancer: A case report

RATIONALE

Pancreatic cancer is common in people older than 40 years, and the incidence peaks at the age of 70 years and older. Chemoradiotherapy has been generally considered a high-risk procedure in elderly patients with local recurrent pancreatic cancer. Gamma knife stereotactic radiosurgery has the advantage in protecting the surrounding tissues, and providing short-term effects. It has been successfully used in patients with brain metastases.The efficacy of GKSRS in other malignancies has barely been studied.S-1 is one of the key drug against metastatic and local advanced pancreatic cancer. The combination of GKSRS and S-1 in local recurrent pancreatic cancer has hardly been reported.

PATIENT CONCERNS

We present a rare case of a 76-year-old man with pancreatic cancer. He complained of recurrent abdominal pain and chronic pain in the right shoulder for more than 3 years.

DIAGNOSES

After several examinations, the diagnosis was carcinoma of the pancreas.

INTERVENTIONS

A resection of the pancreatic neoplasm was performed on June 21, 2011; he did not receive adjuvant chemotherapy. In April 2014, postoperative recurrence was confirmed in the head of the pancreas. The patient received gamma knife stereotactic radiosurgery (GKSRS) combined with S-1 treatment.

OUTCOMES

The patient showed complete response after 2 months. He has achieved an overall survival of 76 months with a very good performance status.

LESSONS

GKSRS applied to other malignancies has rarely been reported. S-1 is the key drug for adjuvant chemotherapy in resected pancreatic cancer. There are a few studies on this combination in local recurrent pancreatic cancer. GKSRS combined with S-1 seems to be a good option in improving efficacy and prolonging life in elderly patients with locally recurrent pancreatic cancer.

Effect of pretreatment psoas muscle mass on survival for patients with unresectable pancreatic cancer undergoing systemic chemotherapy

To the best of our knowledge, there are few previous studies that have investigated the effect of decreased skeletal muscle mass (DSMM) on survival in patients with unresectable advanced pancreatic cancer (APC) who are undergoing systemic chemotherapy. Thus, the present study aimed to investigate the impact of DSMM, as determined by the psoas muscle index (PMI) following computed tomography and prior to systemic chemotherapy, on the outcomes of patients with unresectable APC (n=61). The primary endpoint used was the overall survival (OS) rate. The OS rates in the PMI-High group (exceeds the median PMI value in each gender) were retrospectively compared with those in the PMI-Low group (below the median PMI value in each gender), and factors associated with OS were investigated using univariate and multivariate analyses. The study cohort included 31 male and 30 female patients with a median age of 72 years, 13 of whom were stage IVA, and 48 were stage IVB. The median PMI in males was 4.3 cm²/m² (range, 1.6-8.2 cm²/m²), while that in females was 2.3 cm²/m² (range, 0.7-6.1 cm²/m²). The proportion of patients with performance status 0 in the PMI-High group was significantly high, compared with that in the PMI-Low group [83.3% (25/30) vs. 58.1% (18/31); P=0.0486]. Body mass index in the PMI-High group was significantly higher compared with that in the PMI-Low group (P=0.0154). The 1-year cumulative survival rate was 43.3% in the PMI-High group and 12.9% in the PMI-Low group (P=0.0027). Following multivariate analysis, PMI (P=0.0036), prothrombin time (P=0.0044) and carbohydrate antigen 19-9 (P=0.0451) were identified to be significant predictors of OS. In conclusion, DSMM, as determined by the PMI, could be a significant predictor of prognosis in patients with unresectable APC who are receiving systemic chemotherapy.

Pharmacotherapeutic Management of Pancreatic Ductal Adenocarcinoma: Current and Emerging Concepts

Pancreatic ductal adenocarcinoma is a devastating malignancy, which is the result of late diagnosis, aggressive disease, and a lack of effective treatment options. Thus, pancreatic ductal adenocarcinoma is projected to become the second leading cause of cancer-related death by 2030. This review summarizes recent developments of oncological therapy in the palliative setting of metastatic pancreatic ductal adenocarcinoma. It further compiles novel targets and therapeutic approaches as well as promising treatment combinations, which are presently in preclinical evaluation, covering several aspects of the hallmarks of cancer. Finally, challenges to the implementation of an individualized therapy approach in the context of precision medicine are discussed.

Effect of Sipjeondaebo-Tang on the Pharmacokinetics of S-1, an Anticancer Agent, in Rats Evaluated by Population Pharmacokinetic Modeling

S-1 (TS-1^®) is an oral fluoropyrimidine anticancer agent containing tegafur, oteracil, and gimeracil. Sipjeondaebo-tang (SDT) is a traditional oriental herbal medicine that has potential to alleviate chemotherapy-related adverse effects. The aim of the present study was to evaluate the effect of SDT on the pharmacokinetics of S-1. Sprague-Dawley rats were pretreated with a single dose or repeated doses of SDT for seven consecutive days (1200 mg/kg/day). After the completion of pretreatment with SDT, S-1 was orally administered and plasma concentrations of tegafur, its active metabolite 5-FU, and gimeracil were determined by liquid chromatography-tandem mass spectrometry (LC/MS/MS). A population pharmacokinetic model was developed to evaluate the effect of SDT on pharmacokinetics of tegafur and 5-FU. Although a single dose of SDT did not have any significant effect, the absorption rate of tegafur decreased, and the plasma levels of 5-FU reduced significantly in rats pretreated with SDT for seven days in parallel to the decreased gimeracil concentrations. Population pharmacokinetic modeling also showed the enhanced elimination of 5-FU in the SDT-pretreated group. Repeated doses of SDT may inhibit the absorption of gimeracil, an inhibitor of 5-FU metabolism, resulting in enhanced elimination of 5-FU and decrease its plasma level.

Primary pancreatic-type acinar cell carcinoma of the jejunum with tumor thrombus extending into the mesenteric venous system: a case report and literature review

BACKGROUND

Although ectopic pancreatic tissue is common in the upper gastrointestinal tract, the incidence of ectopic pancreatic tissue in the jejunum is low, and malignant transformation in ectopic pancreatic tissue is rare. Furthermore, pancreatic-type acinar cell carcinoma (ACC) developing in the jejunum and ACC accompanied by tumor thrombus are extremely rare.

CASE PRESENTATION

A 78-year-old-woman presented with melena. Abdominal computed tomography images and endoscopic examination revealed a submucosal jejunal mass with tumor thrombus extending into a jejunal vein. The patient underwent a curative resection combined with a partial jejunectomy and partial pancreatectomy. Histopathological examination of the resected tissue showed tumor cells with a homogeneous acinar architecture identical to pancreatic-type ACC and tumor thrombus. Postoperatively, she was followed for 10 months and had no recurrence.

CONCLUSION

We present an extremely rare case of pancreatic-type ACC in the jejunum with extensive tumor thrombus invading into the mesenteric venous system. This type of cancer has not been reported previously but should be considered in the differential diagnosis of a jejunal mass.

Pancreatic Ductal Adenocarcinoma: Current and Evolving Therapies

Pancreatic ductal adenocarcinoma (PDAC), which constitutes 90% of pancreatic cancers, is the fourth leading cause of cancer-related deaths in the world. Due to the broad heterogeneity of genetic mutations and dense stromal environment, PDAC belongs to one of the most chemoresistant cancers. Most of the available treatments are palliative, with the objective of relieving disease-related symptoms and prolonging survival. Currently, available therapeutic options are surgery, radiation, chemotherapy, immunotherapy, and use of targeted drugs. However, thus far, therapies targeting cancer-associated molecular pathways have not given satisfactory results; this is due in part to the rapid upregulation of compensatory alternative pathways as well as dense desmoplastic reaction. In this review, we summarize currently available therapies and clinical trials, directed towards a plethora of pathways and components dysregulated during PDAC carcinogenesis. Emerging trends towards targeted therapies as the most promising approach will also be discussed.

Reassessment of the clinical significance of portal-superior mesenteric vein invasion in borderline resectable pancreatic cancer

OBJECTIVE

The principal objective of this study is to clarify the prognostic significance of borderline resectable pancreatic cancer (BRPC). The second objective is to evaluate the prognostic impact of the depth of pathological venous invasion.

METHODS

The study included 122 pancreatic cancer patients who underwent curative surgery. All computed tomography scans of the patients were retrospectively interpreted and classified according to the NCCN guidelines, version 1.2016, as resectable (-) or borderline resectable (+) in each arterial (BR-A) and venous (BR-PV) involvement.

RESULTS

The overall survival (OS) rate was significantly higher in BR-A(-) patients (n = 94) than in BR-A(+) patients (n = 28) (P = 0.001), whereas there was no difference between BR-PV(-) (n = 101) and BR-PV(+) patients (n = 21) (P = 0.257). In a multivariate analysis, the independent predictors of OS included BR-A(+) (P = 0.002), lymph node metastasis (P = 0.008), pathological venous invasion (P = 0.003), and adjuvant chemotherapy (P = 0.001). Of 39 patients who underwent venous resection, no significant difference was observed between BR-PV(-) (n = 20) and BR-PV(+) patients (n = 19) in resection rate, lymph node metastasis, the presence of extrapancreatic nerve invasion, recurrence rate, frequency of initial recurrence at a liver or local site, and OS. Pathological venous invasion was significantly deeper in BR-PV(+) patients. However, the depth of invasion was not associated with OS.

CONCLUSION

The definition of venous involvement in the current guidelines predicted the depth of pathological venous invasion but not OS in BRPC patients. Further prospective, randomized studies are needed to establish treatment strategies for BRPC patients with isolated venous involvement.

Health-related quality of life in a randomised phase III study of gemcitabine plus S-1, S-1 alone and gemcitabine alone for locally advanced or metastatic pancreatic cancer: GEST study

Objective:

This study was performed to compare health-related quality of life (HRQOL) of gemcitabine plus S-1 (GS), S-1 alone and gemcitabine alone as first-line chemotherapy for locally advanced or metastatic pancreatic cancer in the GEST (Gemcitabine and TS-1 Trial) study and to assess the impacts of adverse events and tumour response on HRQOL.

Methods:

Patients were randomly assigned to receive gemcitabine alone (1000 mg/m² weekly for 3 of 4 weeks), S-1 alone (80, 100 or 120 mg/day twice daily for 4 of 6 weeks) or GS (gemcitabine at 1000 mg/m² weekly plus S-1 at 60, 80 or 100 mg/day twice daily for 2 of 3 weeks). HRQOL was assessed using the EuroQoL-5D (EQ-5D) questionnaire at baseline and weeks 6, 12, 24, 48 and 72. EQ-5D scores, quality-adjusted life months (QALMs), quality-adjusted progression-free months (QAPFMs) and time until definitive HRQOL deterioration (TUDD) were compared among the three groups. The impacts of adverse events and tumour response on EQ-5D scores were analysed.

Results:

Including EQ-5D scores after death as 0, the mean profile was significantly better in the GS than gemcitabine group (difference, 0.069; p=0.003), but not the S-1 group (difference, −0.011; p=0.613). The mean profiles until death were similar in the three groups. QALMs, QAPFMs and TUDD were significantly longer in the GS than gemcitabine group (p<0.001, p<0.001 and p=0.004, respectively), but not the S-1 group (p=0.563, p=0.741 and p=0.701, respectively). Fatigue, anorexia and tumour response were significantly associated with changes in EQ-5D scores.

Conclusions:

GS achieved better HRQOL than gemcitabine alone, resulting a good balance between overall survival and HRQOL benefits. S-1 alone provides HRQOL similar to that provided by gemcitabine alone. Preventing fatigue and anorexia and maintaining better response would improve HRQOL.

Platelet × CRP Multiplier Value as an Indicator of Poor Prognosis in Patients With Resectable Pancreatic Cancer

OBJECTIVE

Thrombocytosis in patients with various cancers has been considered a parameter for poor prognosis; however, its contribution to pancreatic cancer remains controversial.

METHODS

Potential preoperative prognostic parameters (platelets, neutrophils, lymphocytes, the platelet-lymphocyte ratio, the neutrophil-lymphocyte ratio, the serum C-reactive protein [CRP], and carbohydrate antigen 19-9) were retrospectively analyzed in 95 patients with pancreatic cancer. Cutoff values were defined according to receiver operating characteristic curve analysis, and median survival times (MSTs) were compared.

RESULTS

Median survival times (days) significantly differed according to platelet count (high [552] vs low [735], P = 0.017), CRP (high [471] vs low [750], P = 0.001), and carbohydrate antigen 19-9 level (high [639] vs low [765], P = 0.021), whereas there was no difference in the platelet-lymphocyte ratio and the neutrophil-lymphocyte ratio. Multivariate analysis identified thrombocytosis (hazard ratio, 2.015) and CRP level (hazard ratio, 1.771) as independent prognostic factors. The combinatory effects of platelets and the inflammatory response using a platelet × CRP multiplier value could effectively distinguished the MSTs (days) of patients with pancreatic cancer (high [482] vs low [812], P < 0.001).

CONCLUSIONS

Thrombocytosis and CRP influenced pancreatic cancer patient prognosis. Platelet × CRP multiplier is assumed as a useful parameter that reflects the contribution of activated platelets to cancer progression.

Wilms’ tumor 1 (WT1)-targeted cancer vaccines to extend survival for patients with pancreatic cancer

Despite novel chemotherapy treatments, pancreatic ductal adenocarcinoma (PDA) remains a lethal disease. New targeted cancer vaccines may represent a viable option for patients with PDA. The Wilms’ tumor 1 (WT1) antigen is one of the most widely expressed tumor-associated antigens in various types of tumors, including PDA. Recent reports have indicated that WT1-targeted cancer vaccines for patients with PDA mediated a potent antitumor effect when combined with chemotherapy in preclinical and clinical studies. This review summarizes the early-phase clinical trials of WT1-targeted cancer vaccines (peptide vaccines and dendritic cell-based vaccines) for PDA. Moreover, we will discuss future strategies for PDA treatments using WT1-specific cancer vaccines combined with immune checkpoint therapies to maximize the clinical effectiveness of PDA treatments.

Pancreatic cancer

Pancreatic cancer is a highly lethal disease, for which mortality closely parallels incidence. Most patients with pancreatic cancer remain asymptomatic until the disease reaches an advanced stage. There is no standard programme for screening patients at high risk of pancreatic cancer (eg, those with a family history of pancreatic cancer and chronic pancreatitis). Most pancreatic cancers arise from microscopic non-invasive epithelial proliferations within the pancreatic ducts, referred to as pancreatic intraepithelial neoplasias. There are four major driver genes for pancreatic cancer: KRAS, CDKN2A, TP53, and SMAD4. KRAS mutation and alterations in CDKN2A are early events in pancreatic tumorigenesis. Endoscopic ultrasonography and endoscopic ultrasonography-guided fine-needle aspiration offer high diagnostic ability for pancreatic cancer. Surgical resection is regarded as the only potentially curative treatment, and adjuvant chemotherapy with gemcitabine or S-1, an oral fluoropyrimidine derivative, is given after surgery. FOLFIRINOX (fluorouracil, folinic acid [leucovorin], irinotecan, and oxaliplatin) and gemcitabine plus nanoparticle albumin-bound paclitaxel (nab-paclitaxel) are the treatments of choice for patients who are not surgical candidates but have good performance status.

Current therapeutic strategies for advanced pancreatic cancer: A review for clinicians

Pancreatic cancer (PC) would become the second leading cause of cancer death in the near future, despite representing only 3% of new cancer diagnosis. Survival improvement will come from a better knowledge of risk factors, earlier diagnosis, better integration of locoregional and systemic therapies, as well as the development of more efficacious drugs rising from a deeper understanding of disease biology. For patients with unresectable, non-metastatic disease, combined strategies encompassing primary chemotherapy and radiation seems to be promising. In fit patients, new polychemotherapy regimens can lead to better outcomes in terms of slight but significant survival improvement associated with a positive impact on quality of life. The upfront use of these regimes can also increase the rate of radical resections in borderline resectable and locally advanced PC. Second line treatments showed to positively affect both overall survival and quality of life in fit patients affected by metastatic disease. At present, oxaliplatin-based regimens are the most extensively studied. Nonetheless, other promising drugs are currently under evaluation. Presently, in addition to surgery and conventional radiation therapy, new locoregional treatment techniques are emerging as alternative options in the multimodal approach to patients or diseases not suitable for radical surgery. As of today, in contrast with other types of cancer, targeted therapies failed to show relevant activity either alone or in combination with chemotherapy and, thus, current clinical practice does not include them. Up to now, despite the fact of extremely promising results in different tumors, also immunotherapy is not in the actual therapeutic armamentarium for PC. In the present paper, we provide a comprehensive review of the current state of the art of clinical practice and research in PC aiming to offer a guide for clinicians on the most relevant topics in the management of this disease.

Claudin-4 binder C-CPE 194 enhances effects of anticancer agents on pancreatic cancer cell lines via a MAPK pathway

The C‐terminal fragment of Clostridium perfringens enterotoxin (C‐CPE) modulates the tight junction protein claudin and disrupts the tight junctional barrier. It also can enhance the effectiveness of anticancer agents. However, the detailed mechanisms of the effects of C‐CPE remain unclear in both normal and cancerous cells. The C‐CPE mutant called C‐CPE 194 binds only to claudin‐4, but the C‐CPE 194 mutant called C‐CPE m19 binds not only to claudin‐4 but also to claudin‐1. In the present study, to investigate the mechanisms of the effects of C‐CPE on claudin expression, the tight junctional functions and the cytotoxicity of anticancer agents, human pancreatic cancer cells, and normal human pancreatic duct epithelial cells (HPDEs) were treated with C‐CPE 194 and C‐CPE m19. In well‐differentiated cells of the pancreatic cancer cell line HPAC, C‐CPE 194 and C‐CPE m19 disrupted both the barrier and fence functions without changes in expression of claudin‐1 and ‐4, together with an increase of MAPK phosphorylation. C‐CPE 194, but not C‐CPE m19, enhanced the cytotoxicity of the anticancer agents gemcitabine and S‐1. In poorly differentiated pancreatic cancer cell line PANC‐1, C‐CPE 194, but not C‐CPE m19, decreased claudin‐4 expression and enhanced MAPK activity and the cytotoxicity of the anticancer agents. In normal HPDEs, C‐CPE 194 and C‐CPE m19 decreased claudin‐4 expression and enhanced the MAPK activity, whereas they did not affect the cytotoxicity of the anticancer agents. Our findings suggest that the claudin‐4 binder C‐CPE 194 enhances effects of anticancer agents on pancreatic cancer cell lines via a MAPK pathway.

The impact of postoperative adjuvant chemotherapy on the development of nonalcoholic fatty liver disease after pancreatoduodenectomy

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) after pancreatoduodenectomy (PD) is increasingly being recognized as a late postoperative complication, but the main causes have not been fully investigated. This study aimed to clarify the relationship between NAFLD after PD and postoperative adjuvant chemotherapy, focusing particularly on the adjuvant chemotherapy regimens administered.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of 154 patients who underwent PD from April 2007 to December 2013, to identify the clinicopathologic factors most strongly influencing NAFLD development after PD. Moreover, the postoperative adjuvant chemotherapeutic regimen and the course after the cessation of adjuvant chemotherapy were examined in detail.

RESULTS

The incidence of postoperative NAFLD was 26.6% (41/154). The incidence of NAFLD was significantly higher in the patients with than in those without adjuvant chemotherapy: 38% versus 19% (P = 0.016). Multivariate analysis identified postoperative adjuvant chemotherapy (P = 0.021) and remnant pancreatic volume (P < 0.0001) as independent risk factors. The prevalence of NAFLD after PD was higher in patients treated with the S-1 regimen than in those given either regimens such as those containing gemcitabine or no adjuvant chemotherapy. Recovery from NAFLD 1 y after the cessation of adjuvant chemotherapy was observed in 54.5% (12/22) of patients receiving this treatment. In those treated with the S-1 regimen, improvement was more frequent than in those not receiving adjuvant chemotherapy (57.1% versus 11.8%, P = 0.018).

CONCLUSIONS

Considering the development of NAFLD, adjuvant chemotherapy after PD should be cared for the patients with small remnant pancreas.

Retrospective analysis of high intensity focused ultrasound combined with S-1 in the treatment of metastatic pancreatic cancer after failure of gemcitabine

The purpose of this study was to verify the efficacy and safety of high intensity focused ultrasound therapy (HIFU) combined with S-1 in the treatment of metastatic pancreatic cancer after failure of gemcitabine (GEM). In total, 120 patients with GEM-refractory PC who received HIFU and S-1 between Aug 2012 and December 2014 were randomly assigned to 2 groups. The patients in group A (n = 61) received HIFU in combination with S-1 and those in group B (n = 59) were given S-1 alone. S-1 was administered orally twice a day on days 1-14. Cycles were repeated every 21 days. The follow up time was 3~19 months in both groups. The median overall survival (OS) time and progression free survival (PFS) were analysed by Kaplan-Meier method and Logrank test. The pain remission rate of the two groups was compared by χ(2) test. Patient characteristics and prognostic factors were compared. Patient characteristics did not significantly differ between the 2 groups. Median OS was significantly longer in group A (10.3 months) than in group B (6.6 months, P = 0.000). Median PFS was also significantly longer in group A than in group B (5.1 months vs 2.3 months, P = 0.000). Meanwhile, the pain remission rate was markedly higher in group A than in group B (57% vs. 20%, P = 0.000). There were mild side effects and no significant difference was observed between the two groups. The treatment effect was independently associated with a good outcome. HIFU in combination with S-1 might be effective and well tolerated as salvage chemotherapy in the treatment for metastatic pancreatic cancer.

Adenocarcinoma arising from jejunal ectopic pancreas mimicking peritoneal metastasis from colon cancer: a case report and literature review

Adenocarcinoma arising from jejunal ectopic pancreas is very rare. We report a case of a 69-year-old female with adenocarcinoma arising from jejunal ectopic pancreas after resection of advanced colon cancer. She underwent right hemicolectomy for advanced ascending colon cancer (ypT3N0M0, stage IIA) after chemotherapy. Two and half years after colectomy, her tumor markers were elevated, and computed tomography revealed a mass measuring 20 × 20 mm in the small intestine, having an abnormal uptake of ¹⁸F-fluorodeoxyglucose on ¹⁸F-fluorodeoxyglucose-positron emission tomography (¹⁸FDG-PET). Double-balloon enteroscopy revealed a submucosal tumor in the jejunum, and histopathology of biopsy specimens from that lesion showed ectopic pancreas without malignancy. Therefore, peritoneal metastasis from colon cancer concomitant with ectopic pancreas or adenocarcinoma arising from ectopic pancreas was considered as a differential diagnosis. She underwent laparoscopic jejunectomy. Pathological examination revealed a moderately differentiated adenocarcinoma arising from jejunal ectopic pancreas, not peritoneal metastasis from colon cancer. Even if histopathology of the biopsy specimen shows ectopic pancreas without malignancy, adenocarcinoma arising from ectopic pancreas should be considered when the tumor markers are elevated or the lesion has an abnormal uptake of ¹⁸FDG.

Perspectives in the treatment of pancreatic adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) is an incurable lethal disease whose incidence rate is growing. There is no effective screening for detection of early stage tumors and, in most cases, PDAC is diagnosed at advanced disease stages, when radical pancreatic resection is not possible. The aggressive nature of pancreatic tumor cells lies in the complex genetic mechanisms behind their uncontrolled capability to grow and metastasize, which involve essential adaptive changes in cellular metabolism, signaling, adhesion and immunoediting. In addition, PDAC cells promote a dense functional stroma that facilitates tumor resistance to chemotherapy and radiation. During the last two decades, gemcitabine has been the reference for the systemic treatment of PDAC. However, recently, a regimen combining fluorouracil, irinotecan, oxaliplatin, and leucovorin (FOLFIRINOX) and another combining albumin-bound paclitaxel with gemcitabine have shown clear therapeutic advantage in advanced PDAC, with survival outcomes of 11.3 and 8.5 mo on phase III trials, respectively, over single-agent gemcitabine. With the pending issue of their higher toxicities, these regimens set the reference for ongoing and future clinical studies in advanced PDAC. In addition, the efficacy of oral fluoropyrimidine (S-1) has been well documented in Asiatic PDAC patients. The development of therapeutic approaches other than cytotoxic drugs has proven difficult in the past, with only one drug (erlotinib) approved to date. Besides, a number of agents targeting signaling pathways in tumor or stroma cells are being investigated. Likewise, immunotherapies that target PDAC in various ways are the subject of a number of clinical trials. The search for reliable biomarkers with diagnostic and prognostic value using genomics and mass spectrometry methods may facilitate monitoring and refinement of therapies. This review focuses on current understanding of the pathogenesis of PDAC and the latest developments in the treatment of advanced PDAC.

Novel adjuvant therapies for pancreatic adenocarcinoma

Contemporary adjuvant therapy for pancreatic cancer patients following surgical resection includes chemotherapy and chemoradiotherapy. However, the median survival remains approximately 20 months despite multi-modality treatment using gemcitabine or fluoropyrimidine systemic chemotherapy. Adjuvant randomized trials are currently underway to evaluate cytotoxic combinations found to be active in advanced disease including FOLFIRINOX, gemcitabine/nab-paclitaxel and gemcitabine/capecitabine. Immunotherapy using genetically engineered cell-based vaccines had shown promise in resected pancreatic cancer patients during early phase trials, and algenpantucel-L vaccine is currently being evaluated in adjuvant setting in a randomized trial. This review focuses on novel adjuvant therapies currently in clinical evaluation.

Chemoradiation therapy with S-1 for primary squamous cell carcinoma of the rectum: report of three cases

Purpose

Although successful treatment of squamous cell carcinoma (SCC) of the rectum using chemoradiation therapy (CRT) has been reported, a standard protocol has yet to be established. The aim is to ascertain the effectiveness of CRT with S-1 for three patients with SCC of the rectum.

Case presentation

We treated three female patients complaining of rectal bleeding. The patients were diagnosed as having primary SCC of the rectum by means of routine examinations; one of them was a very rare case because of the presence of two lesions in the lower rectum. We treated the patients using CRT with S1 at a radiation dose of 1.8 Gy/fraction given five times weekly (Monday to Friday) to a median dose of 59.4 (45 to 59.4) Gy; S-1 (80 mg/m²/day) was administered orally during radiation therapy. One of three patients had an adverse event involving massive hemorrhage from the tumor. All patients exhibited an excellent response to CRT with S-1; two patients had a complete response, and one patient had a partial response and underwent a posterior pelvic exenteration with advancement flap reconstruction as a salvage treatment. Pathological examination of the resected specimen and lymph nodes revealed no tumor cells indicating a pathological complete response. In this series, the response rate was 100%.

Conclusions

We suggest that CRT with S-1 be chosen as the first-line therapy for SCC of the rectum. However, a large study will be required to establish a safe and effective regimen.