1
|
Seufferlein T, Uhl W, Kornmann M, Algül H, Friess H, König A, Ghadimi M, Gallmeier E, Bartsch DK, Lutz MP, Metzger R, Wille K, Gerdes B, Schimanski CC, Graupe F, Kunzmann V, Klein I, Geissler M, Staib L, Waldschmidt D, Bruns C, Wittel U, Fichtner-Feigl S, Daum S, Hinke A, Blome L, Tannapfel A, Kleger A, Berger AW, Kestler AMR, Schuhbaur JS, Perkhofer L, Tempero M, Reinacher-Schick AC, Ettrich TJ. Perioperative or only adjuvant gemcitabine plus nab-paclitaxel for resectable pancreatic cancer (NEONAX)-a randomized phase II trial of the AIO pancreatic cancer group. Ann Oncol 2023; 34:91-100. [PMID: 36209981 DOI: 10.1016/j.annonc.2022.09.161] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/26/2022] [Accepted: 09/27/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Data on perioperative chemotherapy in resectable pancreatic ductal adenocarcinoma (rPDAC) are limited. NEONAX examined perioperative or adjuvant chemotherapy with gemcitabine plus nab-paclitaxel in rPDAC (National Comprehensive Cancer Network criteria). PATIENTS AND METHODS NEONAX is a prospective, randomized phase II trial with two independent experimental arms. One hundred twenty-seven rPDAC patients in 22 German centers were randomized 1 : 1 to perioperative (two pre-operative and four post-operative cycles, arm A) or adjuvant (six cycles, arm B) gemcitabine (1000 mg/m2) and nab-paclitaxel (125 mg/m2) on days 1, 8 and 15 of a 28-day cycle. RESULTS The primary endpoint was disease-free survival (DFS) at 18 months in the modified intention-to-treat (ITT) population [R0/R1-resected patients who started neoadjuvant chemotherapy (CTX) (A) or adjuvant CTX (B)]. The pre-defined DFS rate of 55% at 18 months was not reached in both arms [A: 33.3% (95% confidence interval [CI] 18.5% to 48.1%), B: 41.4% (95% CI 20.7% to 62.0%)]. Ninety percent of patients in arm A completed neoadjuvant treatment, and 42% of patients in arm B started adjuvant chemotherapy. R0 resection rate was 88% (arm A) and 67% (arm B), respectively. Median overall survival (mOS) (ITT population) as a secondary endpoint was 25.5 months (95% CI 19.7-29.7 months) in arm A and 16.7 months (95% CI 11.6-22.2 months) in the upfront surgery arm. This difference corresponds to a median DFS (mDFS) (ITT) of 11.5 months (95% CI 8.8-14.5 months) in arm A and 5.9 months (95% CI 3.6-11.5 months) in arm B. Treatment was safe and well tolerable in both arms. CONCLUSIONS The primary endpoint, DFS rate of 55% at 18 months (mITT population), was not reached in either arm of the trial and numerically favored the upfront surgery arm B. mOS (ITT population), a secondary endpoint, numerically favored the neoadjuvant arm A [25.5 months (95% CI 19.7-29.7months); arm B 16.7 months (95% CI 11.6-22.2 months)]. There was a difference in chemotherapy exposure with 90% of patients in arm A completing pre-operative chemotherapy and 58% of patients starting adjuvant chemotherapy in arm B. Neoadjuvant/perioperative treatment is a novel option for patients with resectable PDAC. However, the optimal treatment regimen has yet to be defined. The trial is registered with ClinicalTrials.gov (NCT02047513) and the European Clinical Trials Database (EudraCT 2013-005559-34).
Collapse
Affiliation(s)
- T Seufferlein
- Department of Internal Medicine I, Ulm University, Ulm, Germany.
| | - W Uhl
- Department of General and Visceral Surgery, St. Josef-Hospital Bochum, Ruhr-University Bochum, Bochum, Germany
| | - M Kornmann
- Department of General and Visceral Surgery, Ulm University, Ulm, Germany
| | - H Algül
- CCC Munich-TUM and Department of Internal Medicine II, TUM, Munich, Germany
| | - H Friess
- Department of General and Visceral Surgery, TUM, Munich, Germany
| | - A König
- Department of Gastroenterology, GI-Oncology and Endocrinology, University Medical Center, Göttingen, Germany
| | - M Ghadimi
- Department of General and Visceral Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - E Gallmeier
- Department of Gastroenterology and Endocrinology, University of Marburg, Marburg, Germany
| | - D K Bartsch
- Department of General and Visceral Surgery, University of Marburg, Marburg, Germany
| | - M P Lutz
- Department of Gastroenterology, Caritasklinik St. Theresia, Saarbrücken, Germany
| | - R Metzger
- Department of General and Visceral Surgery, Caritasklinik St. Theresia, Saarbrücken, Germany
| | - K Wille
- Department of Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, Ruhr-University Bochum, Bochum, Germany
| | - B Gerdes
- Department of General and Visceral Surgery Minden, Ruhr-University Bochum, Minden, Germany
| | - C C Schimanski
- Department of Internal Medicine and Gastroenterology, Darmstadt Hospital, Darmstadt, Germany
| | - F Graupe
- Department of General and Visceral Surgery, Darmstadt Hospital, Darmstadt, Germany
| | - V Kunzmann
- Department of Internal Medicine II, Julius Maximilians University, Würzburg, Germany
| | - I Klein
- Department of General, Visceral, Vascular and Pediatric Surgery, Julius Maximilians University, Würzburg, Germany
| | - M Geissler
- Department of Hematology and Oncology, Esslingen Hospital, Esslingen, Germany
| | - L Staib
- Department of Surgery, Esslingen Hospital, Esslingen, Germany
| | - D Waldschmidt
- Department of Gastroenterology and Hepatology, University of Cologne, Cologne, Germany
| | - C Bruns
- Department of Visceral Surgery, University of Cologne, Cologne, Germany
| | - U Wittel
- Department of General and Visceral Surgery, University of Freiburg, Freiburg, Germany
| | - S Fichtner-Feigl
- Department of General and Visceral Surgery, University of Freiburg, Freiburg, Germany
| | - S Daum
- Department for Gastroenterology, Rheumatology and Infectology, Charite University Hospital Berlin, Berlin, Germany
| | - A Hinke
- Biostatistics, CCRC Cancer Clinical Research Consulting, Düsseldorf, Germany
| | - L Blome
- Biometrics, ClinAssess Gesellschaft für klinische Forschung mbH, Leverkusen, Germany
| | - A Tannapfel
- Institute of Pathology, Ruhr-University Bochum, Bochum, Germany
| | - A Kleger
- Department of Internal Medicine I, Ulm University, Ulm, Germany
| | - A W Berger
- Department of Internal Medicine I, Ulm University, Ulm, Germany
| | - A M R Kestler
- Department of Internal Medicine I, Ulm University, Ulm, Germany
| | - J S Schuhbaur
- Department of Internal Medicine I, Ulm University, Ulm, Germany
| | - L Perkhofer
- Department of Internal Medicine I, Ulm University, Ulm, Germany
| | - M Tempero
- UCSF Department of Medicine, University of California San Francisco, San Francisco, USA
| | - A C Reinacher-Schick
- Department of Hematology, Oncology and Palliative Care, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - T J Ettrich
- Department of Internal Medicine I, Ulm University, Ulm, Germany
| |
Collapse
|
2
|
Simunovic F, Wittel U, Passlick B, Wiesemann S, Czerny M, Südkamp M, Stark GB, Bannasch H. [The use of Deep Inferior Epigastric Vessels to Revascularise Free Flaps for Reconstruction of Complex Oncosurgical Defects of the Thigh and the Abdomen]. HANDCHIR MIKROCHIR P 2018; 50:259-268. [PMID: 29341038 DOI: 10.1055/s-0043-124187] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND The resection of large soft-tissue sarcoma requires reconstruction with free flaps. The choice of recipient vessels is crucial for the success of surgery. PATIENTS We report four cases with large soft-tissue sarcomas with complex anatomical relationships: two tumors of the thigh surrounding the femoral neurovascular structures and two tumors of the abdomen with infiltration of the thorax and the abdomen. All cases received multimodal interdisciplinary treatment. The anterolateral thigh (ALT) flap and the latissimus dorsi (LD) flap were employed twice for defect coverage in this series. In all cases the deep inferior epigastric (DIE) vessels were transposed to the subcutaneous compartment and used as recipient vessels. RESULTS The mean duration of surgery was 694 ± 149 minutes. The mean weight of the tumor specimen was 3069 ± 1267 g. Three flaps healed primarily and one exhibited a minor necrosis, which was treated by excision and secondary suture. There were no cases of abdominal herniation due to the transposition of vessels. CONCLUSION Transposition of DIE-vessels to the subcutaneus compartment is a good alternative for free flap revascularisation in this patient group. In this position, the vessels are easily accessed and used for microsurgery. This technical modification increases the reconstructive possibilities in large and previously irradiated surgical defects.
Collapse
Affiliation(s)
- F Simunovic
- Klinik für Plastische und Handchirurgie, Universitätsklinikum Freiburg
| | - U Wittel
- Klinik für Allgemein und Viszeralchirurgie, Universitätsklinikum Freiburg
| | - B Passlick
- Klinik für Thoraxchirurgie, Universitätsklinikum Freiburg
| | - S Wiesemann
- Klinik für Thoraxchirurgie, Universitätsklinikum Freiburg
| | - M Czerny
- Klinik für Herz und Gefäßchirurgie, Universitätsklinikum Freiburg
| | - M Südkamp
- Klinik für Herz und Gefäßchirurgie, Universitätsklinikum Freiburg
| | - G B Stark
- Klinik für Plastische und Handchirurgie, Universitätsklinikum Freiburg
| | - H Bannasch
- Klinik für Plastische und Handchirurgie, Universitätsklinikum Freiburg
| |
Collapse
|
3
|
Schneider MB, Standop J, Ulrich A, Wittel U, Friess H, Andrén-Sandberg A, Pour PM. Expression of nerve growth factors in pancreatic neural tissue and pancreatic cancer. J Histochem Cytochem 2001; 49:1205-10. [PMID: 11561004 DOI: 10.1177/002215540104901002] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
One of the characteristics of pancreatic cancer is its tendency to invade neural tissue. We hypothesized that the affinity of cancer cells for nerve tissue is related to the presence of growth factors in neural tissue and their receptors in cancer cells. Sections of pancreatic cancer and normal pancreatic tissue were examined by immunohistochemistry for the expression of the neurotrophins NGF, BDNF, NT-3, NT-4, and their receptors TrkA, TrkB, and TrkC, as well as the low-affinity receptor, p75NTR. TrkA expression was found in duct, islet, and cancer cells; TrkB was found in the alpha-cells of the islet only. The anti-pan-Trk antibody (TrkB3), which is presumed to recognize all three receptors, immunoreacted with duct and acinar cells in normal tissue and with cancer cells. The staining with TrkC was similar to that of TrkA. The low-affinity receptor p75NTR was expressed in the neural tissue and in scattered duct cells of the normal tissue only. Duct and acinar cells, as well as neural tissue and cancer cells, showed weak to strong immunoreactivity with NGF. NT-3 expression was noted in capillary endothelia and erythrocytes. NT-4 showed specific staining for ductule cells. The expression and distribution of neurotrophins and their receptors suggest their role in the potential of pancreatic cancer cells for neural invasion.
Collapse
Affiliation(s)
- M B Schneider
- Eppley Institute for Research in Cancer and Allied Diseases, University of Nebraska Medical Center, Omaha, Nebraska 68198-6805, USA
| | | | | | | | | | | | | |
Collapse
|